Public Audit and Post-legislative Scrutiny Committee

Meeting date: Thursday, February 18, 2021

Official Report 631KB pdf

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Section 22 Report

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“The 2019/20 audit of NHS Tayside”

Agenda item 2 is consideration of “The 2019/20 audit of NHS Tayside”. I welcome our witnesses from NHS Tayside: Grant Archibald, the chief executive; Lorna Birse-Stewart, the chairperson; and Stuart Lyall, the director of finance. I understand that Grant Archibald would like to make an opening statement.

Good morning, and thank you for giving us the opportunity to present a statement, which my chairman will read.

Good morning. Thank you very much for the opportunity to give evidence this morning. I am pleased to make this opening statement, in which I will set out for members the progress that the NHS Tayside board has made since the beginning of 2019-20.

Prior to the session, we provided a written submission to committee members, which provides an overview of the progress in the key performance areas that were highlighted by the Auditor General for Scotland in his report, “The 2019/20 audit of NHS Tayside.” We have also provided an update on the current position in those key areas and, importantly, NHS Tayside’s financial forecast for 2020-21, which will see the board return to a break-even position one year ahead of our agreed financial plan.

We all recognise that NHS Tayside has been the focus of considerable scrutiny by the committee for several years. Today, we very much welcome the opportunity to present the evidence to assure you that NHS Tayside has returned to financial balance, that it is maintaining strong governance over its financial arrangements and, importantly, that it has achieved this turnaround in performance while delivering high-quality, safe and effective services to the population it serves.

Our new leadership arrangements, which include the involvement of our clinical leaders and teams, have been critical to our achievements. Engaged clinicians at the heart of planning and leading change means that we are ensuring that the redesign, change and, indeed, direction of travel of our organisation are being shaped and driven by clinical and management teams that are directly delivering services to our patients and service users.

There has been a focus on partnership working, with our staff-side colleagues also engaged across key areas of work, to ensure that the voices of our staff are strong in all our joint endeavours to improve health and social care services for the people of Tayside. Those working partnerships at the front line, coupled with the strengthened executive leadership team that has been shaped and delivered by the chief executive, have been critical to the success of the rapid response of the organisation to Covid-19 and our on-going delivery of services throughout the pandemic.

I would like to draw attention to a real-time demonstration of the successes of the new leadership model in Tayside: our ability to mobilise a whole-system response, unprecedented in scale and pace, to Covid-19. Our team not only successfully delivered a Covid-19 hospital within a hospital in the space of just a week; it opened Scotland’s first Covid-19 community assessment centre, in collaboration with general practitioner colleagues in Tayside. They were at the forefront of testing, with NHS Tayside’s model for staff and household testing for the virus hailed as an exemplar.

In terms of our strengthened financial position, the committee has heard previously about three key factors that the Auditor General reported were the main contributors to NHS Tayside’s historical overspend position. For reference, those are the cost per in-patient, prescribing in primary and secondary care and staffing. I shall briefly address each of those in turn.

On cost per in-patient, the most recent national figures for the average cost per in-patient case show that NHS Tayside has the second-lowest average score per in-patient of the four teaching boards in Scotland, with an improving position over the past two years.

On prescribing, I am pleased to report that our cost per weighted patient, which is the measurement used nationally, shows that we are now in line with the Scottish average. Indeed, we are maintaining that position. We also have underspends in secondary and GP prescribing in 2020-21.

On staffing, NHS Tayside has reduced its supplementary staffing spend by £3 million in 2020-21. That is against an increase in headcount, as we are investing in our workforce in many areas by creating substantive positions to stabilise our services further and deliver our new clinical models.

However, I would like to assure committee members that the improvements in our financial position have not come at the expense of service quality or reduced performance, or had an impact on patient experience. That can be evidenced as we look to our service delivery performance, in which we have not only maintained, but improved performance in several key areas, which I will highlight.

Our four-hour emergency department performance remains the best of all NHS boards. We are achieving the cancer 31-day and 62-day targets, and we are delivering the child and adolescent mental health services performance standard. In January, our performance was 96.3 per cent against the 90 per cent target. I thought that it might be helpful as a reference point to note that, in 2018, the performance level was 47 per cent.

All those improvements—and the continuing response to the pandemic—are being delivered as a direct result of the professionalism and commitment of the more than 13,000 people that we have working inside NHS Tayside. I would like to take this opportunity, as would my executive colleagues, to pay tribute to all our health and social care staff in Tayside and, indeed, in Scotland for their continuing contributions every day, particularly at these most challenging times.

I have referred to the executive leadership team. In terms of building on the strengthened executive leadership team, I would like to highlight that there have also been significant changes to board membership in the past two years, with an almost entirely new non-executive board membership and a new chair. As you will be aware, I was appointed substantive chair last year.

The board leadership team recognises that, in a similar way to all other organisations in the country, we require to review our operational plans and our strategic plans as we look at how to live with and, indeed, deliver health and social care services in the time of Covid-19. As you will be aware, all boards are finalising their remobilisation, recovery and redesign plans for 2021-22. NHS Tayside’s plan will be the major vehicle to transform services across Tayside, reflecting the current Covid—and, indeed, post-Covid—environment.

One area that remains an absolute focus in our plans is mental health services. Mental health comes to every board meeting. Dr David Strang’s independent inquiry report, “Trust and Respect—Final Report of the Independent Inquiry into Mental Health Services in Tayside”, made 51 recommendations, of which 49 were for NHS Tayside to deliver.

Can I interrupt you, please? This is all extremely helpful and welcome, but we usually just have a two-minute statement at the start of the meeting. I ask that you draw your remarks to a close, please.

Our mental health strategy will be launched next week and David Strang is due to return to Tayside to review progress.

In summary, we look forward to the further opportunity in today’s session to present the evidence and data that NHS Tayside is firmly on course to achieve and deliver financial balance sustainably, while continuing to improve services for the population who we serve.

Thank you very much for that extremely useful summary. I say to members that I wanted to take that full statement, which I know is outwith the usual parameters of the committee, because I thought that it would be useful to do so. I thank Lorna Birse-Stewart for that full explanation.

I put on record my personal thanks, and those of the committee, to the staff of NHS Tayside for their heroic efforts throughout the Covid pandemic, which really started to hit us last February. It has affected all our lives immensely. We are all indebted to the nurses, doctors, management, allied health professionals, porters and all the staff for their bravery and commitment. They have all gone more than the extra mile to make our country and its population safe during this time. I hope that you will pass on our thanks to them—their efforts really are appreciated.

It is the committee’s job to scrutinise what the Auditor General lays before us. This is the sixth report from the Auditor General on NHS Tayside under the section 22 powers in the Public Finance and Accountability (Scotland) Act 2000. It is worth noting that there is improvement. Some of the structural issues that the report addresses predate the pandemic and it will be our job today to scrutinise those, along with the improvements that have been made during the past year. There is no one happier than me to see the improvement, so I congratulate the board on that. There are some outstanding issues, as the chair and chief executive know, and we will do our best to scrutinise those today.

I draw your attention to the issue of staff vacancies. Since the Auditor General laid his report, I have been quite confused about some of the vacancy numbers. This could be a statistical glitch, but I would like some clarification on the issue, if possible. The Auditor General wrote to me, as convener of the committee, on 16 December 2020—I think that you have a copy of the letter. Exhibit 5 in the letter shows the vacancy rates of consultants across Scotland. NHS Tayside records no vacancies whatsoever as of September 2020. Can you confirm that that is correct?

I can answer that, convener. Yes, you are correct in stating that that is a statistical issue. That is not correct. We are carrying vacancies in our consultant workforce, as is the rest of Scotland. Our most up-to-date figures would be clearer in articulating where we are. As ever, we would be prepared and happy to provide that to the committee. For example, there was particular interest in our staffing of mental health consultants. If you would like—I would not presume—convener, I could give you more information on that. I know that, as a local MSP, that has been an area of keen interest to you.

It has, but it has also been of keen interest to the committee. We have done a lot of work on mental health and children’s mental health specifically. It has been a real issue of concern for the whole Parliament this year. If you could give me those statistics now, that would be very helpful.

09:15  

There are 70 funded consultant psychiatrist posts in NHS Tayside across all services, including community services. At this time, 45.5 of them are filled by national health service employees, who are directly employed by the board. Seven are termed NHS locums—that is, people who locum in the NHS and are employed on NHS terms. Fourteen are locums, who are people we are contracting with either through an agency or individually to provide service. That leaves 3.5 vacancies, two of which are in child and adolescent mental health services. I will come back to that, if you would like me to.

Today, the situation that we are in is that we are relying on locums to maintain our mental health services. I would like to be clear that our desire, irrespective of the hard work of locums, is that our own workforce provides services and that we employ people directly, so that they are vested members of NHS Tayside in its broad family of employment. We continue to work in that area and seek to recruit to those posts.

The locums are valuable to us in continuing to provide the service at the moment. However, it is fair to say—I have seen the evidence previously and the Auditor General refers to it—that there is a shortage of consultant psychiatrists in the United Kingdom, not just in Scotland and certainly not just in Tayside. That makes it very challenging for us to fill the posts. The predictions are that there will not be a surfeit of consultant psychiatrists in training across the UK, so we are looking at the extent to which we can run a less medicalised model, and at how can we redesign models that involve nurse consultants or other practitioners. I am pleased to advise that we are pursuing that avenue, as well as continuing to seek to recruit to the posts that we have.

Thank you—that is very helpful. You said that there are 3.5 vacancies in CAMHS. Maybe my knowledge is a little bit out of date, but am I right in thinking that the full complement in CAMHS is seven?

It is nine; 3.5 is the total number of vacancies, and two of those are in CAMHS. I am sorry if I did not make that clear. We have made other arrangements for that service that have led to the improvement. Irrespective of the challenges that I face in having full-time employment and full consultant establishment, my obligation is to the young people of Tayside who are in need, so we made alternative provision using other resources. I am very pleased and proud to see the improvement that we have made in CAMHS, not only because of our interest in it and our passion for it in Tayside but because this committee has been keen to understand when the improvements will be seen.

Is that how you have managed to get the performance figures for CAMHS from 47 per cent up to 96.3 per cent? I think that that is what Lorna Birse-Stewart said.

Yes.

Is that non-medicalised? Basically, you are referring children not necessarily to a consultant but to someone else who can help them—is that correct?

May I take a moment to explain, convener?

That would be helpful.

One of the challenges with CAMHS when I and Lorna Birse-Stewart and others came into the leadership team was that not only were there people who had been waiting longer than 12 weeks, but there was a very long Poisson tail of people who had been waiting a very long time. My commitment to the board—this is reflected in the board minutes—was that it would take us some time to improve the 12-week guarantee because I needed to deal with those who had waited the longest. We would all want that for our children.

The arrangement that we put in place was very similar to the waiting list initiatives that have been run in other services when the health service has found itself under pressure. We engaged a company called Healios, which provides an end-to-end service involving consultants in psychiatry and nurses. We quality assure that process. It is not just about the first engagement that the child has, as they can have up to seven. Every year, we are seeing about 1,200 new patients and that is the statistic that is counted.

What we must understand is that that is but one statistic and there are a lot of other things going on. I utilised that help because my commitment was to do something that changed the paradigm of where we were, and we needed to do it as quickly as we could. My board was very forbearing and understanding that that one statistic would not improve until I had dealt with the backlog that had built up over a considerable time. I hope—and we will demonstrate it through assurance processes—that the experience for children in Tayside is far better now than it was. Certainly those in need—those reaching out for help either through our websites or through other mechanisms—can be assured that we will get to them quickly and that we will wrap services around them.

That is very helpful. You might expect criticism for bringing in other consultants, but I think that the children who are on those waiting lists desperately needed to see someone. On my last visit to CAMHS, in my private conversations with consultants they told me that many of the problems that they were seeing could be dealt with by other avenues and in a more creative but attentive way. That model is very welcome. I hope that, when circumstances change, I might have the opportunity to visit. It is very helpful and the committee will be encouraged to hear that, because the statistics were quite stark and we wondered how those changes had come about.

Let me turn to one more issue before I bring in Colin Beattie. Can you commit to the long-term presence of a breast cancer service in NHS Tayside?

Colleagues will be aware that there have been challenges in the delivery of breast cancer services in Tayside. As you would expect, there is a highly committed team of staff working in the provision of those services but, in recent months we had one person return to their native country and another consultant resign from NHS Tayside. At this time, we are being supported by colleagues from Aberdeen, which is welcome. That is the aid that we would look for.

Our wish absolutely would be that we provide local services for local women. However, I cannot give a guarantee if the staffing is not available. I will give an absolute commitment to the committee, as I do to the population of Tayside, that we look to provide excellent and safe services—safe for staff, safe for patients, safe for everybody—using all efforts to provide exemplary services across the range of NHS care in Tayside. In this area, it has been difficult. It has been difficult for the staff. I will need to find ways to ensure that we can recruit to this service before I can give an absolute commitment and guarantee that the service will be there. I will guarantee my commitment to wish to have local services for local women.

My fear is that, if a service is not sustainable in the long term, there will be women in Dundee who will not travel for breast cancer treatment. Oncology services in Dundee and Tayside have been exemplary for many years. We will not rehearse all the recent difficulties with the breast cancer service, but they were very much to do with clinical governance and arose through no fault of any patient. It would be a grave shame if that service were not sustainable because of those problems at a high level. Perhaps it is something that we can come back to, because I feel very strongly that it is very important that this service is maintained at Ninewells.

I will make two further points. The first thing is that the absolute commitment is to provide local services for local people where we are in a position to provide them safely and appropriately. That is our aim and our commitment. I welcome the opportunity within the confines of the committee or beyond it to demonstrate our efforts to do so in a way that is safe for patients and staff and safe for everyone. We need the broader population of Tayside to know and to be confident that we are committed to providing those services, which we are.

I, too, express my genuine appreciation for the hard work and dedicated efforts of NHS staff in Tayside.

Looking specifically at issues to do with the transformation of services, when the chair made her opening remarks, she touched on certain of the key points. To me, there are three key issues in the transformation process: staffing costs, in-patient costs and prescribing costs. This is the sixth section 22 report on NHS Tayside. I have sat here after each section 22 report—all six times—and listened to improvements that we are told are in the pipeline or have been executed. We have been assured that everything is coming right financially, but sometimes it just does not happen and, next minute, we have another section 22 report. Why will it be different this time?

In preparation for this meeting, I looked at the transcripts and broadcasts of the previous meetings that NHS Tayside had attended. I saw your comment, Mr Beattie, on what is different—“Is the team up to it?” was one of your questions, I think. I will say two or three things in response.

The first thing is that you see a very different team from the one that was here before. Up until now, 13,000 people have been working incredibly hard in an incredibly committed way across NHS Tayside for all the years that you have been listening to the senior team describe what is happening. Their commitment and hard work should never be underestimated.

The challenge for me coming in as the new chief executive was how we change effort into outcome, how we achieve delivery rather than aspiration and how we evidence for the people of Lochee, Pitlochry or Montrose that things are different and things are better in Tayside and how we rebuild their confidence. That has been a hard road, to be honest, Mr Beattie. It has been difficult, but we have created a new team. I have a new medical director, a new nurse director, a new finance director and a new director of public health. You know that we have a new board.

What we have concentrated on doing is not describing effort to you but demonstrating action, so I will stop there. I will bring in Stuart Lyall at the end of my comments to state to you that these are the facts and these are the reasons why we want you to believe that NHS Tayside—team Tayside—is on the case and is improving the situation. Sitting here and telling you that we will deliver financial balance a year early is very different from two or three years ago, when the Auditor General said in a report that it was the most daunting challenge that she had ever seen. We are keen to demonstrate to you today through evidence, not through commentary, that we are better.

You ask why it is better this time. It is better because we have committed not to talk about how hard we are working and how committed we are to the NHS, because that is a given, but to show that it has improved, to show that we are demonstrating what the Government would expect, which is value for money, to show that we are learning either from ourselves or from others and to show that services are better. I am proud of the improvements we have had in cancer services and in CAMHS.

I will hand over to Mr Lyall, who can give some very specific indicators, if that is acceptable.

I would like to start by giving the committee, and Mr Beattie in particular, assurance that the facts that we have on financial performance are what they are. We know the 2019-20 position and you have had the report from the Auditor General. I am confident that we will deliver financial balance this year. In fact, we are on course to deliver an underspend and therefore we will balance out across the three-year planning cycle that we operate in. Boards should break even across a three-year period rather than in each year in isolation.

09:30  

We required £7 million of financial assistance in 2019-20. Last year’s overspend was a planned overspend. It was part of a planned and structured approach to getting ourselves back into financial balance. Indeed, the Auditor General himself, through our annual audit report, has commented on improvements in our financial control, our financial governance and our financial reporting. We have a clear set of figures that we report through our board and we have a level of confidence in delivery on those. We have overdelivered the past two years and we will break even this financial year. I am in discussion with the Scottish Government about how we balance the position over the three years and how we pay back some of the £7 million from last year.

We are in a stable position. Importantly for me, the way in which we have set up our service model, with the engagement that we have from the new executive team and from our clinical leadership, means that that is sustainable. It will not be a one-off year in which we break even; it is sustainable. We have looked at service models; we have looked at pathways; we have looked at waste and variation; we have looked at efficiency; and we have looked at productivity. We have looked at all the things that you would expect us to look at, but in a way that is focused on quality. As an executive team and as a clinical leadership team, we believe that, if you focus on quality, the money drops out—rather than doing it the other way round.

The results are what they are; the facts are what they are. We will be audited at the end of the year and I am comfortable that we will deliver an underspend position and we will be in balance.

Can I come back to the point that I made at the beginning? There are three key drivers in the transformation process. One is reducing staff costs, which the chair commented on. I would like a bit more detail about that and about the use of agency staff and so on. I do not think that in-patient costs were touched on. I understand that prescribing costs have been driven down. I would like a little more granularity about how that was achieved.

On in-patient costs, the data that you have from the Auditor General is for 2018-19. We are talking about a 2019-20 section 22 report and we have just had the 2019-20 figures made available to us. We are below the average for teaching hospitals in both 2018-19 and 2019-20 in terms of our in-patient costs. You would expect us, as a teaching hospital, to have a slightly higher cost base because of the complexity and the range of services that we undertake.

Our approach to in-patient models has been to look at pathways of care and our productivity. It is about getting our patients in the right place in the pathway, so if they should be in the community, they are in the community rather than in expensive acute hospitals, and when they are coming through our theatres, we are pushing through the right number of patients and they are getting the appropriate treatment and so on. We have focused on the metrics that you would expect us to focus on and we have those at a much better level. We improved in six out of nine of those that we measure internally in the last financial year. Again, I would emphasise the clinical leadership involvement and engagement in that, which has allowed us to take costs out of the system. On in-patient costs, I am comfortable that we benchmark well within Scotland. We always seek to improve. We continue to look to improve because we know that there are challenges coming up in the years ahead, as we all recognise.

There are two similar issues with prescribing. For GP prescribing or community prescribing, we set up a prescribing management group a number of years ago that had a focus on waste and variation. Again, we had involvement from GPs, we had clinical leaders from the health and social care partnerships, we had our own director of pharmacy and managers and we had support staff with data and so on. Using the data to model where we should be and where we could be, we have been able to take costs out of the system. The chair mentioned that we are now in line with the Scottish average cost per weighted patient. A few years ago, we were close to 10 per cent above that average. That is a significant change in our spend profile over that period. In financial terms, that is about £7 million-worth of savings. That is through the engagement and—

Mr Lyall, can I interrupt? What you are saying is very interesting, but the committee does not have any evidence on that other than what you are saying today. Is it possible for you to supply the committee with clear information on the improvements that are being made and how they are being made?

Yes, we can provide you with a report. We have a whole series of minutes from meetings over a number of years. We can pull together comprehensive reports, which we take to our performance and resources committee every quarter. The summary positions will show the steps that we have taken and you will be able to see the change in the variation. You will be able to see that we are now aiming for an underspend position and that we will deliver an underspend position.

In her opening remarks, the chair said that there had been a £3 million saving on staffing costs. That is a lot of money. Where exactly has that saving been extracted?

The saving has come predominantly through agency costs. In nursing, we have taken steps to recruit as best we can, given market conditions, to stabilise our staffing models. We have done that across all staff disciplines. From my perspective, recruitment is good. It stabilises the services and it costs less. Clearly supplementary staffing, particularly agency staff, is expensive and is not stable for patient care and staff experience.

Did £3 million come from cutting agency staff? I would not have thought it was—

It was directly from cutting agency staff.

That is a big saving. Do you have many vacancies at consultant level and so on that you are managing in order to get the staff costs down?

We do not use vacancy management as a tool to get staff costs down. As I say, I would prefer that we employed staff rather than spent money on agency costs. I am comfortable that we have a budget that reflects the staffing that we need to deliver the services that we need to deliver. I would prefer that our clinical teams recruited up to their establishment level. We try not to carry vacancies where we can get people into post and that is—

At the moment, do you have many consultant posts that are being held vacant?

Sorry—I am not sure whether you are still speaking, Mr Beattie. Your screen is frozen.

I am trying to ascertain whether we have a lot of consultant posts that are being held vacant at the moment.

We have vacant consultancy posts, but we do not have consultant posts that are being held vacant deliberately. There is a difference between—

How many consultant posts are vacant?

I do not have a figure to hand for how many consultant posts are vacant at this time.

Along with the other information, perhaps you could supply that for the committee.

I will.

Could I come in quickly on that point before Colin Beattie moves on to Covid-19? One of the committee’s frustrations is that we do not have the figures on consultant vacancies, as I explored with Grant Archibald. He gave me a breakdown of CAMHS. We do not have time to go through that for the whole thing, but the Auditor General’s letter of 16 December set out that statistical glitch, saying that you had no vacancies. In your submission to the committee, you did not set out the current position. It is frustrating for the committee that we are not being given the full information, which led to Mr Beattie’s questions. Mr Beattie, I will hand back to you.

I am interested to know how Covid-19 might have accelerated the transformation programme, if indeed it did. I am not sure who that question is for.

That is a question for me. To follow up on the previous question, we will supply the information. We are keen to evidence our position.

The challenge with Covid-19 is that we recognise that the whole world has changed but we do not know how it has changed. Every organisation, whether it is in health or anything else, is having to regroup and think about what its service will look like in future. That is exactly what we are doing. That is why I said that our plans for the next year and the immediate term should be about remobilisation, and that it should reflect the Covid situation and the immediate post-Covid situation.

That brings challenges. Stuart Lyall talked about efficiency and one of the areas that we were looking to for further efficiency was throughput in theatres, attendance at outpatients and so on. The traditional way of doing that is now impeded by the amount of effort that one needs to put in with personal protective equipment, the slowing down, the cleaning between theatre patients and so on. That means that we need to be adaptive.

If I could take the other side of that as adaptive, we have Near Me video or telephone consultations. We had been working for quite some time to redesign our outpatient services and because of the force majeure of Covid, we have gone from something of the order of 400 Near Me consultations in a month to 200,000 in the year to date. That is transformational and we need to understand why the population was keen to engage in that way. Is that a way to deal with rurality when we engage with people across 3,000 square miles?

What lessons are we learning from Covid? What do the next nine to 12 months look like? That is the reality of where we are—ourselves, the airline industry and everyone else. What will our vault spring be into a full recovery mechanism?

If I might take your time for one moment, Mr Beattie, in this period let us not forget that babies have been born, people have been attending accident and emergency and chronic conditions such as those that require dialysis have needed to be treated. The health service has had to keep providing in a strong way the whole series of services that it would normally provide. We have dealt with Covid for 332 days now and probably have at least another 100 days to go. In addition, we will have to recover our elective programmes and see those who need replacement hips and knees and other types of surgery. That is the planning that we are doing.

We will submit our recovery plan to the Government at the end of this month, in keeping with its timescale. Our previous recovery plan—and it should be on the record at the Scottish Government—was identified as exemplary because we reflected the new world, the new challenges and how we will all work to deal with those.

Mr Archibald, you are telling us a lot of good things, but we do not have the detailed evidence supporting that. Can you provide such evidence so that we can review what you are saying? We need much more detailed evidence. You will understand that for some years now we have had a lot of promises and a lot of assertions. Show us the evidence.

We look forward to the opportunity to do that. All we want to demonstrate is the efforts that we have made and the outcomes that we have gained from those efforts. As I said, effort is not the issue; the issue is the outcome for patients. We will demonstrate that in value for money and in services delivered. The Auditor General’s report was quite some time ago—it covered the previous financial year. What we were trying to articulate to you—not least in response to your call in previous meetings about where the evidence is—was that, even in this time of Covid, we have kept going. We believe that we have been successful and I will show you the evidence of that.

Following on from the convener’s questions about mental health services, I want to focus on demand. There have been a number of reports in the media from charities and the Scottish Government about the increase in demand for mental health services during the Covid lockdown, particularly for children and young people, and especially young girls and young women. I heard what you said about meeting targets. What impact has Covid had on the demand for mental health services in Tayside? What has been the impact on CAMHS services? Have the targets been hit while demand has been increasing? What has been the impact on demand?

There has been a lot of discussion about mental health services, including as recently as in Parliament yesterday. We are all mindful that, if we are in lockdown on and off, and people are out of their jobs for 330-odd days, it will have an impact on their mental health. In keeping with everyone else, we are trying to assess that impact, but we are not just doing it as health; we are doing it with the Tayside executive partners, which are the three councils in the Tayside area, and with our HSCPs.

The mental health strategy document that we have produced, “Living Life Well”, is all about trying to harness the different sources of information that we can garner to understand what will happen next. People talk about a mental health time bomb, but what does that mean? I am keen that we understand where the new need is for the population of Tayside and where there might be unmet need, such as with people who are living alone, people who have not seen families, people like myself who have lost relatives during this period and have not been able to go to funerals, and so on. What has that done to people’s mental health?

09:45  

On the specific question of demand, that has been higher than normal. We are concerned there is unrecognised need—or at least unquantified need—out there. We will take guidance from Government and others—not least off the back of the announcement that was made yesterday—about how we reach out to those people. Through our website, our engagements and our constant video postings, we have certainly made it very clear that NHS Tayside is open to help you, whatever your condition. When we talk about the challenges that mental health will present as a result of Covid, it is important for us to get some pretty good indicators for that. My sense and my colleagues’ sense is that this will be a significant challenge for us, and I think that that was reflected yesterday during the debate in the Parliament.

It is a significant challenge across the country and it has obviously been a significant challenge in Tayside. It is encouraging to hear that improvements have been made.

What additional resources have you allocated to allow mental health services to cope with that increased demand? What impact will it have on meeting your targeted savings in the medium term? Do you anticipate having to spend significant additional resources on mental health services in the coming year to keep pace with that demand? What impact will that have on other areas that we have mentioned today as potential areas that you might need to make savings in?

I will take that in three sections, Mr Bibby. First, on what we are doing with the demand that we have, I have talked at length about CAMHS and the fact that we have put in additional resource specifically to drive a better outcome. We are pleased about that and we will continue to support that service.

Secondly, we are aware that mental health services in Tayside face many challenges. That is why we had the David Strang review, “Trust and Respect”, and why we have our own response to that in “Listen. Learn. Change.” and in the “Living Life Well” mental health strategy, which we will launch next week.

The third point is about the additional demand that is presenting and how we will manage that. As I say, quantification of that and how it might best be dealt with is an important issue for us. What will that mental health challenge look like and how well set are we to deal with it? We welcomed the minister’s announcement yesterday that specific and additional resource will be allocated to that.

I hope that we have not overplayed the challenge of Covid in trying to represent to the committee what else we have been doing in running our services, but I think that we all need to be mindful that it has had a huge impact, and we are yet to understand what its future impact will be. Support from Government will be essential, and we seek not only to think of it in our own terms, but through learning from our neighbouring boards. Finally, the role of public health in all this will be incredibly important.

You mentioned the Strang report, which raised a number of serious concerns about disclosure of information, communication with bereaved families and a lack of confidence in the complaints handling process. You mentioned “Listen. Learn. Change.”. What have you done to engage with families to restore their confidence in local services? How have you done that specifically during lockdown, given the complexities that there are in engaging with people during a global pandemic?

To be clear, David Strang’s report was incredibly important to the organisation because it laid out a series of concerns and 51 recommendations. More than a year ago, when we were still allowed to meet, the director of nursing and I engaged with a group of bereaved families in the Apex hotel. I gave them my personal commitment that improvement of the management of mental health would be a primary target and commitment of the board. We have continued to reiterate that.

Since that time, we have had a series of engagements through communications groups and engagement groups. We have also been engaging with the stakeholder participation group, which was a group of concerned relatives that came together. Through our interim director of mental health, the construction of our strategy for the future, “Living Life Well”, has been a co-production, with us listening to their voices. Something of the order of 1,300 voices were heard through that process—I will check that number, if you do not mind. Our intention was to have a series of what might be described as town hall meetings, where I, the director and other people from the service would sit and listen to experiences. That has been less possible at this time, so we have done it using Teams and Zoom calls. Those engagements have been taking place. They are documented in our “Living Life Well” document, which we will launch next week. Going back to Mr Beattie’s point, that is further evidence to show members of the committee that NHS Tayside is doing as well as I am describing.

The post of director of public health has now been filled, has it not?

The director of public health post has been filled, yes.

Permanently?

Permanently, yes. We have an excellent appointee, who is making a huge contribution.

Good morning. At the previous evidence session, I had some difficulty understanding the relationship between the integration joint boards and the figures surrounding them. In his letter in December, the Auditor General gave us some further information on that. Can you explain why there are different arrangements with IJBs? How do those arrangements work and do some work better than others?

I will start on that, Mr Bowman, and then bring Stuart Lyall in. Engagement between HSCPs and IJBs is complex. You are bringing together different and complex organisations. It was a learning process that was started a few years ago. Stuart Lyall will describe the financial arrangements to you because I know that that was a key point of interest.

On how we work together, the three chief operating officers of the IJBs attend our board meetings and are part of my executive leadership team for NHS Tayside. We work collaboratively together and they co-report to me and to the chief executive of each of their respective councils, of which there are three in Tayside. We also have the IJBs themselves, on which there are members from the health board as well as from the council to advise and take forward the strategies in those areas.

You are right that the risk sharing and funding arrangements are different between the different organisations. That was how they were originally established.

If I have dealt with the first part of your question and you are content, I will pass on to Mr Lyall to comment on the funding.

On funding, the IJBs have a range of services delegated to them from the health board and the council. With that comes resources and budget. Funding is devolved down to the IJB level and spend is monitored against that as we go through the year, as you would expect.

What happened in the case of Dundee in particular, and in Perth to an extent, was that, at the end of the year they had a level of overspend. Dundee was underspending on the budgets that were traditionally devolved to health, but was overspending on the budgets that were devolved to social care. The split between them matters to an extent in terms of reporting, but the IJB will look at that as one resource. They would not tend to separate the two out between health and social care. They have one resource to smooth that out across the service profile.

We have an integration scheme with each of the three HSCPs in Tayside. Broadly speaking, they apportion any overspend—or indeed any underspend; that can also happen—in proportion to the level of budget that has been devolved down to the IJB. The Auditor General picks that up in one of his national reports. Broadly speaking, health contributes around 70 per cent of budget to the IJB, social care being the balance. For Dundee, the overspend that it had in the previous financial year was split between ourselves with two thirds, and the council with one third.

Perth has a slightly different integration scheme. It is just a play on words, whereby the NHS picks up any health overspend and the council picks up any social care overspend. That is the nature of the integration scheme, which, as the chief executive said, was set out back in 2016 at the establishment of IJBs.

Thank you for that. Part of my concern is that there is so much more to explain what is happening in the information that we got from the Auditor General, unless I missed it somewhere in the financial statements. I am concerned about the two-thirds split with Dundee. The rest of Tayside is subsidising the Dundee social care budget overspend, to the cost of other areas. Can I ask the chair whether she is satisfied with that?

Clearly, the schemes of delegation in the three integration schemes are different. As the director of finance outlined, that is because of the way in which they were formed in 2016.

There are clear differences across the three IJBs. I will pass back to the chief executive in a moment, but I want to highlight that one of the real positives that has come out during the pandemic—if indeed there can be positives—is the joined-up working that we referred to with the local chief officers of the three IJBs working very closely through the Covid-19 pandemic. They are also on our gold and silver commands.

I joined the board three years ago and I have seen a significant change in the relationships at IJB level. The board has moved to provide continuity in membership from the health board to those IJBs. I will pass back to the chief executive to talk about performance.

As the chair and Stuart Lyall have described, Mr Bowman, the original schemes of integration go back some time. The Derek Feeley report might cause them to be revisited, but that is where we are. There is a challenge that we perhaps need to articulate more clearly, which is this: we expect all parts of our organisation to deliver on budget. That is our challenge, because Mr Bowman used the word “subsidising” and no one likes to think that they are working hard but the money is being spent elsewhere. We need to continue to engage with our IJB partners and assist and work with them to make sure that balanced budgets are returned, as they are in the NHS and in councils.

It is only because we asked for that information that it has come to be a focus. Do you know how the current year is looking, in terms of the table that we got from the Auditor General?

I will ask Stuart Lyall to comment on that.

In the current year, we expect each of the HSCPs to break even. That is certainly the forecast. The chair and chief executive have described the relationships, and there has been significant strengthening of those in recent years. I have to commend the work that has been done in the partnerships across Tayside to deliver that financially balanced position to support the board and the equity of the use of resource across our full population.

What you are saying is that what jumps out as an issue this year in these figures will not jump out the next year, because people are meeting their budgets. That is comforting.

That is what I am saying, yes.

10:00  

I want to explore the section of the Auditor General’s report on financial sustainability. There is a paragraph that says that, in 2019-20, there were “recurring savings” of £14.3 million, which was 40 per cent of the funding gap. It says that, although that is a decrease from 44 per cent the previous year,

“the board remains significantly reliant on non-recurring savings.”

It also says, rightly, that

“This situation is not sustainable”.

What is the percentage of non-recurring savings? What are you doing about that?

We look to increase and achieve the highest level possible of recurring savings as part of our redesign of services. As Stuart Lyall has described, we are trying to redesign services in a way that drives financial improvement rather than setting arbitrary targets.

In the past three years—in the two years that I have been chief executive, and in the time that Stuart Lyall and Lorna Birse-Stewart have been in their posts—we had to demonstrate that we could get ourselves back to financial balance. The other challenge was to do that while protecting the staff, the patients we serve and the services we provide. We are keen to reinforce today that that is what we have been doing, and we will provide further evidence in that regard. In the current year, our level of recurring savings has increased significantly, as Stuart Lyall will describe. Our aspiration is to continue to achieve recurring savings, but there will always be a level of non-recurring savings. I am dealing with an organisation that spends almost £1 billion, has 13,000 staff and serves 416,000 people. It is a big endeavour, and we will need some flexibility in how we work. Stuart Lyall can articulate those points.

In terms of our current performance on the delivery of recurring savings, we are sitting at 55 per cent in 2020-21. It was 40 per cent last year and will go up to 55 per cent this year. It is important to note that the level of recurring savings that we deliver will fluctuate from year to year. We have a £1 billion organisation and will always have a level of non-recurring savings, as we will always have a level of non-recurring cost. Those are features of an organisation of this complexity and size.

In terms of our recurring savings performance over the years, I talked about a planned and structured approach and that is what we are delivering. In dealing with some of the legacy issues, we have had different levels of recurring savings. Now, as we move into remobilisation and into delivering services in a different way, the delivery that we have had so far gives us a solid foundation to go forward and make structural service change, which will increase that level.

As director of finance, I can say that we are now sitting at a level that, although it is not comfortable, is manageable. A few years ago, we had an unsustainable level of what I would term an underlying recurring deficit, arising from an overreliance on non-recurring savings. We have now halved that. We have reduced that level by 50 per cent in the space of three years. We will seek to reduce that further as we move forward into the next year of our financial plan.

You say that the level is manageable but, according to what you have just said, 45 per cent of the savings that you have at the moment are non-recurring. That still sounds high to me. Does it sound high to you?

If we look at our relative performance nationally, the Auditor General’s reports on the NHS in Scotland from 2019 showed us as the best-performing territorial board in terms of delivery of recurring savings. We are performing within the pack in terms of what you would expect from a health board of our size.

With the non-recurring element, we recognise that we will get a level of savings every year, but it will come from different places from year to year. We would not term that recurring. We will get the same amount out of non-recurring savings; they will just come from a different area, if that makes sense. We can always improve, but I am comfortable that, for an organisation this size, we are running at a manageable level.

It might help the committee if you can give us some examples of some of the non-recurring savings that you have made.

I can do that.

Do you want to list some now?

Non-recurring savings could involve a range of what we would call housekeeping issues. We talked about productivity and efficiency. Savings in those areas can be recurring savings in terms of delivery. A lot of the housekeeping issues we deal with are non-recurring in nature because they come from a different area each year. We might have one particular area of service that is quiet in terms of activity one year, but is busier the next year, which means that the saving that we made the year before is not recurring. It covers a range of things across a range of costs that we incur as an organisation. There is not a deliberate targeting of particular areas. It could be staffing; it could be non-pay; it could be in theatres; it could be in the community; or it could be in drugs. For example, in prescribing, we have continued our performance and we have reduced the cost by £2 million this year, but I expect that to go up next year as demand goes up. That is why that is a non-recurring saving.

That is useful. Thank you.

I would like to address a slightly different aspect of the sustainable funding. Since 2017, the amount of money given to NHS Tayside has fallen quite sharply below the Government’s NHS Scotland resource allocation committee—NRAC—target by at least £20 million, according to figures that I have seen from the Scottish Parliament information centre.

Has NHS Tayside been given everything that it needs to adequately fund the likes of breast cancer awareness and mental health issues now and once the pandemic is over?

We have been well supported, in my experience, by the Scottish Government over the past two years, and in particular by the director of finance and the director general of health and social care. The challenge for us is to articulate where we think we are legitimately in need of additional resource, driven either by activity or by other issues. One area would be waiting list initiatives to help us deal with waiting list pressures that are beyond the means of the board to deal with. An example of that to come will be mental health, as was articulated yesterday.

There was a view some years ago that NRAC shares were out of kilter and they were realigned across Scotland. In all our engagements with the Government, we are keen to demonstrate that we are managing the resources that we get and that, when we make a claim for any additional resource, it is legitimately evidenced on the basis of genuine need beyond the current budget envelope of the board. There can be specific examples of that, particularly if a target changes, for example.

I feel that we have been well supported. There are conversations about making sure that we secure the level of resource that we think is appropriate. Like this committee, we need to evidence our work. When we have done that, I have felt supported.

If you got what you might call your fair share, would you have to go and ask for more or would you have the resources to do what you want to do?

This is a complex environment. Things change—targets change; demand changes—and, every year, there is a negotiation around the budget. That is entirely appropriate and is a process that we need to be involved in. On that basis, we are given an allocation and we are expected to live within it. We are in front of you today to demonstrate where we are with that. As Mr Beattie said, we have come on a long journey of six or seven years. We are getting ourselves back to a point of financial balance. The challenge is to continue to engage with Government colleagues to ensure that the Tayside allocation of resource is commensurate with us being a teaching environment and also with the needs of our population.

We are running a little bit short of time. Bill Bowman, if you are satisfied that we might receive that information by post or by letter, we will move to Gail Ross.

When the committee reported on the 2016-17 and 2017-18 audits of NHS Tayside, it indicated that it was essential that new board members had the requisite skills and diversity to suitably equip them to challenge and scrutinise the senior management team. Do you feel that your board has the requisite skills? Do you feel that they are sufficiently holding you to account?

As you will be aware, over the past two years the board has made significant efforts through the public appointment process to uplift the non-executive membership of the board. In 2019, we had non-executive support from NHS Greater Glasgow and Clyde in terms of our audit risk and finance oversight. I was glad that, a year ago, through the public appointment process, we appointed three new non-executives with a particular focus on audit risk and finance. Due to a couple of recent retirements of long-standing board members, we are in the process of recruiting through the public appointment process additional non-executive experience to broaden the mental health and public health portfolios. A year ago, we established a public health committee as a standing committee of the board and therefore have populated that.

In terms of the board and the skill mix, a lot of time and consideration has been given to ensure that we have broad portfolios represented on the board, so that it can provide challenge and scrutiny and also be a critical friend to executive functions. We are running with an almost completely full board of non-execs with a broad skill mix. Two additional appointments are coming, which I expect we will have by the end of April, which will also stand us in good stead as we move into the remobilisation planning. Does that cover the question?

It covers the skills part. What is the gender balance, or what will it be when you have recruited your new members?

I expect our gender balance to be roughly even, at about 50 per cent, following the public appointment process. I have been involved in two of the previous rounds and I know that certain skills in certain areas come through the public appointment process.

In this recent round, we have had an exceptional response to the public appointment process. That enhances our ability to reflect diversity across the board, not just in gender, so that we have a fully balanced board. It is important that we have a balanced board in that respect as well.

Grant Archibald, what is your opinion of the skills and diversity of the board? Is it holding you to account?

It absolutely is. We should recognise that, probably uniquely in Scotland, this is an incredibly young board and an incredibly young team, not just in terms of their temporal ages but in terms of how long the team has been together. I have been in the health service for 37 years and I have been impressed by the level of scrutiny and the level of challenge that we get when I, Stuart Lyall, my director of public health or my medical director take papers to the board.

10:15  

Do we feel held to account? Absolutely, we do. The board members take the time to scrutinise the papers and where they do not understand something or where they think that the direction articulated is not their understanding of what is going on, they are keen to explore that with us. There is challenge and there is grit in all of that. Given the history of the board, we see that challenge in committees such as the audit and risk and finance committees in particular, but we also see it around our clinical services.

I have felt supported by my board, entirely so. However, I understand that that support is earned by demonstrating the quality of the services that we are delivering. If we are seen to be falling short, the challenge, the scrutiny and the need for answers is there from my board.

Thank you. I am happy with that, convener.

I thank you all for your evidence this morning. After six years, it is heartening for us to see signs of hope and good progress within NHS Tayside. We appreciate you taking time during this challenging period to report to the committee.

I will now suspend the committee for five minutes for a changeover of witnesses.

10:16 Meeting suspended.  

10:21 On resuming—