Meeting of the Parliament

Meeting date: Thursday, September 20, 2018

Official Report 1286KB pdf

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NHS Tayside Board

Good afternoon. The next item of business is a statement by Jeane Freeman on NHS Tayside Board. The cabinet secretary will take questions at the end of her statement, so if any members wish to ask a question, they should press their request-to-speak button as soon as possible.

I would like to update the Parliament on developments in the governance of NHS Tayside since the changes to its leadership earlier this year.

In April this year, following clear concerns over the board’s service delivery and management of resources, including the board’s use of endowment funds, John Brown and Malcolm Wright were appointed as chair and chief executive of NHS Tayside. Malcolm Wright and John Brown are two of the most senior and experienced leaders in the national health service in Scotland. Their immediate remit was to strengthen the governance and leadership of the board and to improve public and stakeholder confidence.

Their first step was to meet with directors, non-executives and clinical leaders to clearly set out their joint and shared aims for improvement and to listen and respond to concerns about the challenges facing the board and how each could contribute to addressing those and taking the board forward. The principles that they set out on that first day—of visible leadership, openness and honesty combined with challenge and accountability—have continued to define the priorities pursued over the last five months.

The top priorities for the new leadership team have been to get a full picture of the situation that they were dealing with right across the whole organisation, to identify the priority areas requiring immediate action and to make best use of the assets and resources at their disposal to remedy those.

In doing so, they have recognised the enormous contribution that the staff of NHS Tayside make each and every day. The approach of the chair and chief executive has been underpinned by a belief that deep-seated cultural and structural matters need to be addressed if delivering reform in the board is to be both effective and sustainable. That is not just about what people do; it is also about how they do it.

The chair and chief executive reviewed all the findings of external reviews and reports carried out over the previous 18 months and identified five priority areas for focused action: providing clearer direction; supporting operational leadership; driving service change; improving financial and service performance; and ensuring effective regulation and compliance.

An important action by the chair of NHS Tayside has been to commission an independent governance review, covering the role of the board, the role of board members, the capability and capacity of board members to deliver against that role and the effectiveness of the information systems and administrative arrangements necessary to support the board.

Given its importance to the NHS, an independent review of information governance and cybersecurity arrangements has also been completed, and the Chartered Institute of Internal Auditors has reviewed the effectiveness of audit arrangements in Tayside.

The chief executive has taken decisive action to strengthen his executive leadership team in key areas, including finance and human resources, as well as rolling out a system that supports staff to make decisions at the most appropriate level. That work has been complemented by the development of a comprehensive performance management system in order to make performance visible and the lines of accountability clear. Oversight of that work is the responsibility of the performance and resources committee, which was introduced to put scrutiny of performance and finance in the same arena.

A new, clinically led operational management system has been put in place that puts clinical leaders in the driving seat, with devolved budget responsibility. Crucially, that is accompanied by a development programme to ensure that they are supported in fulfilling the new roles. The clinical leaders are supported by dedicated operational managers, which is an approach that creates a collective responsibility for improving patient care.

The establishment of a clinical alliance group has also provided a forum to encourage whole-system approaches and the design of innovative solutions that tackle both immediate challenges and longer-term reform.

The newly appointed strategic director of workforce has set in train a safe, affordable workforce process, with the devolution of workforce changes to a local level.

On prescribing, which was highlighted in Sir Lewis Ritchie’s report as the other key cost driver in Tayside, a continued and unwavering focus on driving out unwarranted variation and waste is being complemented by a public health-led approach that is aimed at addressing the systemic factors that drive prescribing behaviours and expectations.

All of that is necessary to deliver the kind of sustainable reform that is envisaged by our chief medical officer in her realistic medicine programme.

Partnership working is being promoted at every level within the organisation, which brings us back to the point that I started with—the importance of openness, honesty and engagement from the internal infrastructure of partnership working to the strengthening of engagement with external stakeholders, including many colleagues who are in the chamber today.

The new leadership team has been at the forefront of the board’s response to important issues that have emerged over the past few months, including the recently commissioned independent inquiry into mental health services across the board area.

On the management of endowment funds, we have already taken action to further strengthen the governance around the issue to mitigate any risk that is posed by dual membership. Once the Office of the Scottish Charity Regulator has completed its independent inquiry into the management of endowment funds in Tayside, the chair and chief executive will also lead on any further action that may be required.

The work of the chair in engaging with non-executive directors has led some to choose to stand down as the new leadership team has become embedded, having helped to support the transition to the new arrangements.

I was advised on Wednesday 12 September that three non-executives had intimated their wish to resign from their positions. Both Mr Cross and Mr Hay initially considered resigning in April of this year, when action was taken to change the leadership of NHS Tayside, but following discussion with the acting chair, both decided to remain to assist the new chair and chief executive and to help to provide continuity and assist with the review of governance for NHS Tayside. Both have now decided that this is the right time to resign from their roles so that fresh non-executive input can be brought on to the board. I am genuinely grateful to them for their commitment and the positive role that they have played in providing stability to the board in recent months.

A further non-executive, Mr Hussain, has indicated that he will resign following his current period of sick leave. He wrote to me on 31 August—I received the letter on 3 September—on a number of matters, which I immediately followed up on, and I have been assured by the chair that the matters that Mr Hussain raised are being properly dealt with.

I am aware that other board members are also considering their future plans in the light of the significant work that has been undertaken around the governance of the board and the clarity that it has provided on the role of board members in providing challenge and scrutiny and in taking responsibility for doing that.

The board will consider a full report on its governance mechanisms at its meeting on 25 October. I am in regular contact with John Brown—I met him this week—and I have received an assurance that the board’s work will continue to meet its responsibilities. He has also confirmed that Trudy McLeay, one of the recent non-executive appointments to NHS Tayside, has agreed to be the board’s new whistleblowing champion. I have passed on my thanks to her for taking on that important role.

I expect new non-executive appointments to be made early in the new year following a full values-based appointments process regulated by the Commissioner for Ethical Standards in Public Life for Scotland.

I will continue to support the new leadership in NHS Tayside building for the future. In addition to agreeing to suspend the repayment of brokerage for three years, I have agreed to provide additional funding, including support to give clinicians the time to make the commitment to clinically led change a reality. I am clear that the need for organisation-wide culture change and sustainable recovery in NHS Tayside will require sustained and agile intervention and leadership of the highest calibre.

I put on the record my thanks to John Brown and Malcolm Wright for their effective and focused work so far, and to the staff of NHS Tayside, who have engaged with and supported the approach and the work that is necessary to ensure the good and effective governance that is essential to the delivery of quality, safe healthcare.

The cabinet secretary will now take questions.

I thank the cabinet secretary for advance sight of her statement.

I send the message to our NHS staff in Tayside that we value them and the work that they do. I know from many emails, phone calls, letters and conversations that I have had with friends of mine who work for NHS Tayside just how low staff morale has fallen in the organisation in recent months and years. That does nothing for staffing and patient care.

We heard that Mr Hussain has written to the cabinet secretary to identify a number of matters, which she said that she felt the need to immediately follow up. What are those matters?

Given the now imperative need to recruit a long-term leadership team for NHS Tayside, and given the crisis in leadership that we have seen over many years now, does the cabinet secretary agree that the Parliament’s Health and Sport Committee should be given an additional scrutiny role for future appointments?

I thank Mr Briggs for the support that he has offered to NHS Tayside staff.

The matters that Mr Hussain raised with me covered doctors in training, prescribing, senior management pay, the use of public funds, child and adolescent mental health services, and transformation. All those matters have been followed up. I will write to Mr Hussain with my responses to all of them, but they are all being followed up by the board. For example, the chief executive of NHS Tayside discussed with our chief medical officer and our chief pharmacist the dosage issue that Mr Hussain raised, and Health Improvement Scotland is conducting a fact-finding review. That will be followed up by a more wide-ranging review by the Royal College of Physicians in London, which NHS Tayside commissioned.

On the scrutiny role that Miles Briggs asked for, the values-based recruitment process that we now undertake very successfully in some of our boards, which is being rolled out for the current round of chief executive appointments, provides significant scrutiny and challenge. At the end of that process, there are, of course, other steps that have to be gone through to ensure that the person is fit to be the accountable officer before any recommendation comes to me. A comparable process is gone through for the chair. That approach is right for our board appointments at that senior leadership level.

I would be very happy to keep the Health and Sport Committee apprised of how we are progressing on that matter, but we have an appropriate and robust level of scrutiny, challenge and checks within our current arrangements to ensure that we secure the best possible senior leadership for our health service in Scotland, particularly through that values-based recruitment process.

I thank the cabinet secretary for prior sight of her statement.

There is a crisis in public confidence in NHS Tayside following a series of issues, which include financial mismanagement leading to brokerage loans; the raiding of the charity endowment fund; a chief executive and a chair being forced to resign; the issues at Carseview leading to an independent mental health inquiry; and the failure to suspend a consultant after repeated concerns were raised.

The cabinet secretary made passing reference to the now former whistleblowing champion Munwar Hussain. I have seen the letter that Mr Hussain sent to the cabinet secretary, in which he said:

“On the 27th June 2018 I received a direct email from an ex-doctor in training who had managed to get my e-mail address. Noting that”

they

“had left the NHS due to issues of systematic bullying and negative cliques and highlighting this issue for others within the organisation.

Further, there were claims that people were raising issues, but these were not being acted upon by managers. Including allegations in the email that a previous trainee took their own life and the stress was unbearable for some.”

That is a serious set of allegations, which includes the claim that a trainee took their own life due to stress.

Mr Hussain went on to say that he had asked for that to be raised at a board meeting, but was told that he could not do so. He twice attempted to meet the strategic director of workforce in August but, both times, the meetings were cancelled. Eventually, he raised the matter at a staff governance committee meeting, but he

“felt that this was viewed as an on-going issue that is tolerated”.

Why does the cabinet secretary feel reassured that the matter is being dealt with adequately, when the person whose job it was to ensure that it was dealt with adequately did not believe that it was—so much so that he resigned?

I am grateful to Mr Sarwar for that supplementary additional question. There are undoubtedly challenges for NHS Tayside, which I would not underestimate in any respect. There are challenges across our health service; we have heard about some of them in the chamber before and undoubtedly we will rehearse some of them again. I take all concerns that are raised with me, directly or by any other means, very seriously indeed.

In the specific instance, which Mr Sarwar has quoted, of the junior doctor—the ex-doctor in training—raising those issues, the appropriate place for the whistleblowing champion to raise the matters is, indeed, in the staff governance committee and not in the wider public board meeting. That was why it was not appropriate to raise the issue and talk about individuals in those circumstances in that public forum.

The General Medical Council report on the quality of junior doctor training in mental health services will be at the next NHS Tayside staff governance committee and the specific allegations that were reported via that whistleblowing are currently under investigation. The chamber should rest assured—I give members my absolute assurance—that I will continue to monitor how those matters progress. That is on the basis of the board responding appropriately, in my opinion, to the whistleblowing issues that have been raised with it. I have the assurance that those issues are being dealt with, and I will continue to monitor how the board deals with them and what the end results will be. I am happy to continue to advise my colleagues across the chamber of progress as it is made.

I thank the cabinet secretary for early sight of her statement and I put on record my thanks to NHS Tayside staff for all that they do.

In its report on NHS governance, the Parliament’s Health and Sport Committee recommended that there should be staff involvement in the process of appointing whistleblowing champions for boards. The cabinet secretary’s response to the report mentions a consultation on new whistleblowing standards. How will those standards address the situation in which the NHS Tayside whistleblowing champion found himself, with concerns being escalated but not clearly acted upon, and how will they set out standards for staff involvement?

The cabinet secretary noted that legislation would be introduced in the autumn to establish an independent national whistleblowing officer for NHS Scotland, to go live by the end of September 2019. Is that still on track? Is that timeframe acceptable, and what can be done to expedite further support for whistleblowers now?

I thank Ms Johnstone for her questions and for her support for NHS staff on Tayside.

On the involvement of staff, NHS Tayside board has, as other boards have, a partnership forum that directly involves representatives of staff from across the board. Matters that go to the board are discussed in the partnership forum, which is represented through the employee director who sits on the board.

I understand, from the information that members have about Mr Hussain’s letter to me—if they have had sight of it, or seen media coverage in the Sunday Post last Sunday—that there is a claim that whistleblowing claims were escalated but not clearly acted upon. From the information that I have received from the board about how it is dealing with the matter—part of which I have made available today to Mr Sarwar, and I am perfectly willing to make that available more widely to other members—I do not share the view that those whistleblowing issues have been escalated but not acted upon. That is precisely what I have sought assurance upon: that not only have the claims been escalated, but they are being acted upon. I believe that I have that assurance, and I have already stated that I will continue to keep a close eye on how those matters progress as the board goes through its proper processes. As I have said, I am very content to keep members up to date with progress as it is made.

On another matter, Ms Johnstone asked whether we are on track—we are on track with the appointment and the timescale.

I thank the cabinet secretary for advance sight of her statement.

As a result of Anas Sarwar’s revelations to Parliament, I will depart from my prepared question. On a failure of whistleblowing systems this serious, can we really expect the board to mark its own homework? As such, does the cabinet secretary agree that it is in our national interest to bring these issues into the light, and will she today instruct a full independent public inquiry into whistleblowing practices in north Tayside?

I assume that Mr Cole-Hamilton wants an independent inquiry into the whole of Tayside and not just one bit of it. I do not believe that that is necessary.

On 3 September, very serious claims by a member of NHS Tayside’s board were communicated to me by email. On 11 September, having been absent due to ill health, that board member indicated his intention to resign. The board has acted on those concerns. As I have said, I saw the actions that the board took prior to Mr Hussain getting in touch with me. I have made a commitment that I will keep a close eye on how those matters progress, and I will keep the chamber up to date on that.

The board is absolutely not marking its own homework. I understand and share members’ concern about this issue, but we need to be very careful about the language that we use. As I have said, NHS Tayside has asked the Royal College of Physicians in London to undertake a review of the dosage issue. The GMC will be involved in terms of the allegation about doctors in training—the single doctor who raised the whistleblowing matter.

On the issue about senior management pay and the public reporting of pay and expenses, a paper will go to the board in October proposing that the board publish not only pay scales but expenses.

Issues relating to CAMHS have been discussed in the chamber many times. Members, the Government and the NHS Tayside board are acting on those issues.

I refute the notion that on matters as serious as this, the board—or indeed any other board—marks its own homework. That is absolutely not the case. As I have said, I will keep members updated, via another statement if that is what members wish, or by other means, on the progress of the specific issues that have been raised, within the wider context of the significant steps that the acting chair and the acting chief executive are taking with senior staff and others in Tayside to improve the scrutiny and governance of the board.

Given the importance of the role of non-executive board members, how can health boards and the Scottish Government ensure that people with the right skills are recruited to those posts?

There are ways in which we go about recruiting to non-executive member posts and to important posts in other public bodies. In the health service, we use what we describe as values-based recruitment. The intention behind that recruitment exercise is that it allows applicants to display more than one dimension of their capability and capacity—in other words, we look at the values that they bring, as well at as their experience of particular tasks.

Non-executive board members are critical to our health service. There are issues in Tayside, but we can see issues more widely elsewhere in the United Kingdom, where absence of effective scrutiny and challenge by non-executive members of boards leads, at the very least, to poor decisions being made. It is important that non-executive board members not only understand the information that they are given and are given the right information to allow them to exercise their function, but that they pursue their challenges.

The recruitment process that we now have in place will offer us the opportunity to have an even more robust view of the individuals who come forward to what is a very responsible role that requires a lot of their time, energy and expertise. That is how we recruit, interview, select and determine for the role of non-executive board members.

One final step that it is important for chairs to take is the annual review of how individual board members are performing in their role, which is robust. This Monday, I will have a further discussion with the chairs of all our boards about how we can ensure that such reviews are consistent across the boards, because they inform future appointments of members both to the health board concerned and to any other board in the health service.

The cabinet secretary said in response to an earlier question that 27 June was the date when she first received information about the matter—or the Scottish Government did. Was it the previous health secretary who received the information or was it Ms Freeman?

I think that Liz Smith is referring to the point that Mr Sarwar made about Mr Hussain saying that he raised the matter of the board. Mr Hussain’s letter to me is dated 31 August—he sent it to me by e-mail on 3 September. That was the first point at which I became aware of the specific concerns that he raised. When he sent me the letter on 3 September, he raised the matters with me and asked for what he described as a period of “special leave” because of his health. There is no such thing as special leave, so he was advised to seek his general practitioner’s involvement. He has, since then, been on sick leave, although on 11 September he intimated his intention to resign when his period of sick leave is over.

Members have referred to the Health and Sport Committee’s report on the governance of the NHS in Scotland, which highlights among other things the importance of monitoring and assessing whether changes in support for whistleblowers in NHS bodies are effective. I note from the cabinet secretary’s response to the report that there is no intention to hold the dignity at work survey in 2018, which is one of the means by which the NHS is able to assess staff’s views of the support that is available to them. What else does she have in mind to monitor the views of staff who feel bullied, harassed or under pressure as a consequence of whistleblowing or other issues?

I am grateful to Mr Macdonald for raising that matter and to the committee for its report, which I read in great detail and to which I have responded. I believe that I am due to meet the committee to go through some of the matters in detail, because the report raises an important series of issues and relates to further steps that we might take.

I believe that we have already dealt with the dignity at work survey in the chamber—we discussed the level of response to it. On the iMatter survey, the response rate for NHS Tayside staff compares well with the rate for the health service across the piece: there was a 63 to 65 per cent response rate, or engagement rate, from them.

In respect of the overall grid showing how people viewed their position, NHS Tayside is at the top level in some areas, but it needs to improve in others. The staff governance committee and the partnership forum in NHS Tayside should be actively looking to make improvements, in particular in the area that Mr Macdonald raised.

As members will know, each board is subject to an annual ministerial review of its performance. This year, I personally will conduct NHS Tayside’s review, and that is one of the areas in which I will be looking to see what progress it has made and how that has been received by staff when I meet the clinical forum and the partnership forum.

I have not had sight of emails that Anas Sarwar or anyone else received, but I note the mention of openness, honesty and whistleblowing in the cabinet secretary’s opening statement. We have covered dignity at work and other areas in the Health and Sport Committee. Can the cabinet secretary expand on exactly what will happen regarding whistleblowing, honesty and openness to ensure that it really is safe and acceptable for staff to speak out—especially in confidence—about matters that they think should be highlighted?

As I indicated in my statement, there is a new whistleblowing champion at board level in NHS Tayside. We have already covered the other initiatives that are being taken around national whistleblowing.

However, I record that in relation to NHS Tayside, what I said in my statement stands and deserves repetition—we are looking to secure significant cultural and structural reform in NHS Tayside. Such cultural reform is critical in all boards, so I will be looking at them all to ensure that they are behaving in a manner that I believe is appropriate in relation to how they engage with staff, how they involve staff, and how welcoming they make it for staff at any level in any part of a health board’s operation to raise concerns and to have confidence that those concerns will be listened to seriously and acted on, and that they will be advised about what has happened as a result.

In some instances, concerns will be raised that prove to be ill founded. They will not have been raised in a malicious way, but when the facts are looked at, it might be seen that there is no particular foundation for concerns. Nonetheless, if a member of staff’s view is that something is cause for concern, that should be treated seriously.

All such matters will be looked at. We will look at the other boards to ensure that they are operating in the manner that I believe is essential for them actively and fully to make best use of their most significant resource—our staff who work in the health service. Every single one of the ministerial reviews of boards for this year that will be conducted by me and my two ministerial colleagues will focus on that and on a range of other matters.

Last year, it was revealed that NHS Tayside had a severe problem with workplace bullying. Respondents to a questionnaire highlighted that they did not trust their managers enough to tell them about it. The current whistleblower development—we have heard quite a shocking list of concerns today—also involves a lack of trust in management’s capability to take things seriously.

The actions that the cabinet secretary has spoken about in relation to NHS boards overall are one thing, but NHS Tayside’s actions have not worked out so far for the staff there. What will the cabinet secretary do specifically for NHS Tayside staff, who are very mistrusting of management, to stop the situation from continuing?

I am grateful to Mr Bowman for raising that issue. It is a serious issue when NHS staff—it is serious for staff in any organisation, but my focus is on NHS staff—say that they do not trust their management to take their concerns seriously or that they fear that if they raise concerns, there may be repercussions for doing so. In addition to the steps that I have outlined, when I undertake the ministerial review of NHS Tayside, I will make a particular point of looking at that issue.

For the benefit of Mr Bowman and others, I say that normal practice for these ministerial reviews involves meeting the clinical forum, which is a mix of clinical staff of all grades, to talk about how they feel matters are being pursued within their health board, and meeting the partnership forum, which involves unions and others who represent staff, including the Royal College of Nursing. However, in this particular instance, I will make a point of also seeking a way to have a wider discussion with staff in NHS Tayside on some of these specific matters.

I will do that without the benefit of having NHS board officials beside me—although obviously I will have my officials with me—in order to try to get under the skin and find out what the issue is about so that we can be assured, or take other steps if needed, on how the current leadership of NHS Tayside is addressing the matters and taking them forward.

Can the cabinet secretary give assurances that all staff at NHS Tayside will continue to be kept informed of any developments?

I believe that I can do that, given the knowledge that I have. For example, I know that the current acting chair, John Brown, regularly issues staff notices to keep staff apprised of what is happening. I believe that a notice was issued either yesterday or the day before with respect to the board resignations, giving staff assurance that the matters that Mr Hussain raised are being dealt with and looked at in detail by the chief executive and the senior team. It also gave assurance to the wider community that, despite the resignations, the board is still able to meet its core statutory responsibilities and its wider responsibilities on integration of health and social care.

In the cabinet secretary’s response to Miles Briggs, she referred to an issue of dosage that is being reviewed. Can she provide details on the conditions to which the dosage review pertains?

In the same response, the cabinet secretary outlined details of the appointment process for the new chief executive. I seek confirmation that the recruitment process has started, because we need a stable and seamless transition in December for the long term.

Can the cabinet secretary give her views on the forecast outturn of an £18.7 million deficit this year in Tayside, which will take Tayside’s debt to the Government to nearly £65 million? How does she plan to get on top of that and give patients in Tayside the confidence that this financial mess is being sorted out?

There were a lot of questions there, cabinet secretary, so perhaps do not go into too much detail on all of them. That was too many questions for the end of the statement.

Thank you, Presiding Officer—I will do my best.

On the specific conditions for the dosage review, I do not have that information before me, but I am happy to seek it and I will advise Ms Marra of it in due course.

On the process for recruiting the chief executive, the preliminary process has begun. Even if we had started that in August or earlier, we would have been unlikely to have a chief executive in post in time, because it takes time to go through such matters. Generally speaking, when we are looking for high-quality leaders, they will be leaving another role and we will have to negotiate their leaving period. However, I am pleased that Mr Brown has agreed to continue as the acting chair until the new chief executive is in post, which I hope will be in the early part of 2019. Of course, we will also begin the process of recruiting a permanent chair of NHS Tayside for the four-year period.

On the finances, we engage actively with boards across the financial year on their financial position. I have made it clear to all boards that, in looking to address their financial challenges, we need to be assured that they are making best use of the resources. However, I have also made it clear that it will not be acceptable for them to take capacity out of their health boards in terms of delivery, because of the direct knock-on impact that that has on patients.

My chief finance officer in the directorate and the health service is actively engaged with NHS Tayside and its board. As members will recall, NHS Tayside is at the highest escalation level for health boards in Scotland, which means that there is detailed and rigorous reporting and scrutiny of all the decisions that the board makes and, in particular, the decisions on finance.