1. The following changes to Committee membership occurred during the Committee's scrutiny:

   • On 10 October 2024, Brian Whittle MSP replaced Tess White MSP.

   • On 30 October 2024, Elena Whitham MSP replaced Ruth Maguire MSP.

Proposed new Care National Outcome

Proposed updated Health National Outcome

Other factors considered

Indicators and measuring success

Cross-cutting policy

Accountability

Funding and budgets

Public engagement

Conclusion

22. The Scottish Government introduced the National Performance Framework (NPF) in 2007 as an outcomes-based framework to underpin the delivery of its policies.

23. To help achieve its purpose, the Framework sets out National Outcomes which the Scottish Government states "describe the kind of Scotland it aims to create¹Scottish Government. (2024). National Performance Framework. Retrieved from https://nationalperformance.gov.scot/about/what-it ".

24. The Community Empowerment (Scotland) Act 2015 requires the Scottish Government to develop and review the National Outcomes every five years and to regularly report progress towards them. The Scottish Government began its latest review process in 2022 with a period of public engagement and concluded its consultation in May 2024 when it laid its proposed changes to the National Outcomes before the Scottish Parliament for its consideration.

25. The Finance and Public Administration Committee has a remit to scrutinise the NPF and is leading the scrutiny of the Scottish Government's review work. The Committee issued a call for views which was open from 13 May 2024 to 28 June 2024. It received 72 submissions, which have been published on the Scottish Parliament website alongside analysis by the Scottish Parliament Information Centre (SPICe).

26. The current NPF has the following 11 National Outcomes:

    • Children and Young People: We grow up loved, safe and respected so that we realise our full potential

    • Communities: We live in communities that are inclusive, empowered, resilient and safe

    • Culture: We are creative and our vibrant and diverse cultures are expressed and enjoyed widely

    • Economy: We have a globally competitive, entrepreneurial, inclusive and sustainable economy

    • Education: We are well educated, skilled and able to contribute to society

    • Environment: We value, enjoy, protect and enhance our environment

    • Fair Work and Business: We have thriving and innovative businesses, with quality jobs and fair work for everyone

    • Health: We are healthy and active

    • Human Rights: We respect, protect and fulfil human rights and live free from discrimination

    • International: We are open, connected and make a positive contribution internationally

    • Poverty: We tackle poverty by sharing opportunities, wealth and power more equally

27. The NPF measures progress against the National Outcomes through 81 National Indicators.

28. The current health outcome has nine indicators. These are:

    • Healthy Life Expectancy

    • Mental wellbeing

    • Healthy weight

    • Health Risk Behaviours

    • Physical activity

    • Journeys by active travel

    • Quality of care experience

    • Work related ill health

    • Premature Mortality

29. The Scottish Government's parliamentary report on its review of National Outcomes, laid before the Scottish Parliament on 1 May 2024, proposes several changes to the NPF and National Outcomes. These include:

    • introducing three new outcomes—Care, Climate Action, and Housing

    • merging the previous "Economy" and "Fair Work and Business" outcomes into a single outcome

    • revising nine of the National Outcomes

    • proposing updates to the extended definitions of all National Outcomes.

The Scottish Government

30. The report also sets out the Scottish Government's intention to revise the National Indicators following the Review of National Outcomes. Scotland’s Chief Statistician will lead this work, which is due to be completed once a revised set of National Outcomes has been agreed with Parliament.

31. At its meeting on 16 April 2024, the Health, Social Care and Sport Committee decided to undertake scrutiny of the proposed National Outcomes to consider the strategic themes related to the health and social care outcomes in the NPF, including how Scotland is currently performing and the health and wellbeing aspects of the NPF. 

32. The Committee held two oral evidence sessions with stakeholders at its 23rd meeting of the Committee in 2024, on 10 September, with particular emphasis on the proposed new Care Outcome and the proposed updated Health Outcome.

33. The new Care National Outcome proposed in the NPF is:

    • We are cared for as we need throughout our lives and value all those providing care

34. The Scottish Government states that the proposal to include a new National Outcome on Care "reflects the requests to acknowledge all aspects of care, paid and unpaid, for those who care and are cared for. It also responds to the findings of the thematic gender review, by increasing visibility of work that is carried out predominantly by women"¹Scottish Government. (2024, May 1). Consultation with Parliament in connection with the Review of National Outcomes. Retrieved from https://nationalperformance.gov.scot/information-hub/consultation-parliament-connection-review-national-outcomes.

35. Oxfam Scotland, the Scottish Women’s Budget Group, Carers Scotland, Scottish Care, and One Parent Families Scotland submitted evidence to the Scottish Government consultation supporting this outcome, with backing from over 50 other organisations. This evidence was supported by research carried out at the University of the West of Scotland through the UWS-Oxfam Partnership, and the “A Scotland That Cares” campaign. The campaign sets out a blueprint for the proposed National Outcome on Care, which includes proposals for a National Outcome Statement and supporting indicators.

36. 10 submissions to the Finance and Public Administration Committee’s call for views make direct reference to the proposed new Care Outcome. The accompanying SPICe summary indicates that respondents generally welcome the introduction of a new Care outcome, emphasising the need for high-quality care services and the rights of carers.

37. In their submissions, respondents call for "improved support structures for both paid and unpaid carers, including fair wages, training, working conditions, respite care options, and financial support". Respondents also highlight the "interconnectedness of care with other social determinants and stress the importance of an inclusive approach that considers the diverse needs of different populations, including disabled individuals and ethnic minorities"²Scottish Parliament Information Centre (SPICe). (2024). National Performance Framework: Inquiry into proposed National Outcomes - analysis of the call for views. Retrieved from https://www.parliament.scot/-/media/files/committees/finance-and-public-administration-committee/nationaloutcomes_spicesummaryofevidence_27aug24.pdf.

38. Witnesses giving evidence to the Committee on 10 September all expressed the view that while the addition of a new Care Outcome was both welcome and useful, a number of additional dimensions would need to be considered. In their view, these included defining levels of need including unmet need, providing a clear definition of those who provide care and determining how the Outcome would be implemented.

39. While welcoming the principle of the proposed new Care Outcome, Emma Congreve from the Scottish Health Equity Research Unit argued that it didn't necessarily reflect the current situation regarding the extent to which delivery of social care in Scotland is meeting the level of demand:

    In Scotland, we have no way of even estimating unmet need and how many people may require care services [...] Although the appetite is there, I think that the outcome feels a bit detached from the ability to realise what is in it. It is a little jarring, given that we know the reality for people who draw on care services in Scotland³Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

    Speaking of the role of unpaid carers in particular, she added:

    Recognising that role and quantifying its value is very complex [...] The ability to recognise that they exist is missing. If the NPF can somehow work out how to measure that through its indicators, that would be very welcome.³Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024]".

40. Professor Cam Donaldson from Glasgow Caledonian University questioned the extent to which it would be possible to ensure that the full array of types of care encompassed by the new proposed National Outcome are accounted for and measured:

    It reflects caring, which is an aspect of society that has been long neglected, partly because much of it is made up of informal care [...] There are questions about what need is and who determines need [...] Also, what do we mean by valuing those who care? A complex array of paid and unpaid carers would be covered by the outcome³Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

41. Witnesses argued that accurately measuring performance against the indicators would be key when it came to determining whether progress towards meeting this new National Outcome was being made. In this context, Professor Chik Collins from the Glasgow Centre for Population Health highlighted the proposed indicators submitted as part of the 'A Scotland That Cares' campaign and outlined a potential framework to enable progress against the new National Outcome to be tracked. Professor Donaldson also added his view on tracking progress:

    I tend to think of these things as 2x2 frameworks that allow us to track what is going on. In this case, I think that we need a framework that allows us to answer two questions. First, who cares? That is, who is doing the caring? I do not mean “who cares?” in the pejorative sense. Secondly, who pays? As part of that, I think that you might have a 2x2x2—who is paid and who is unpaid? That is the framework that we need to put in place to help us to track what exactly happens over time with respect to the outcome³Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

42. Carol Calder from Audit Scotland spoke about the particular importance of the indicators related to unpaid care as well as arguing in favour of suitable mechanisms for determining accountability:

    [...] the devil is in the detail. It will be about what indicators are developed to align with the outcome and the accountability framework to support that. Which agencies will be required to report on those indicators? What will they measure? To what extent will they take into account the issues for carers as well? [...] We would like a clear line of sight between what the agencies involved with carers do and the outcome itself to demonstrate what works and what helps, and to see what does not work so well. It is about the accountability framework that exists between the high-level outcome and what the individual agencies that are involved actually deliver on the ground³Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

43. Representing IPPR Scotland, Stephen Boyd emphasised the importance of establishing suitable frameworks to enable accurate measurement and ensure appropriate accountability across all areas of the NPF. He went on to argue that this would require "a lot of engagement with those whose quality of life you are seeking to measure."

44. In relation to paid carers, witnesses also emphasised the need to ensure the sustainability of the care sector through improved pay and conditions for the social care workforce, as a critical enabler to progress in meeting the proposed new National Outcome.

45. Emma Congreve raised concerns that the new proposed Care Outcome makes no reference to the integration of health and social care, whereas such a reference is included in the health outcome. She stated her view that the Care Outcome needs to "recognise that delivery is by the public, private and third sectors. They all need to be part of realising the ambition³Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024]". Linking this to the discussion on measurement and accountability, she argued that commissioning and procurement could offer the best means of measuring progress:

    [...] we could track the way that care is procured and whether that enables good terms and conditions to be offered to paid carers in the public, private and third sectors. In the third sector, things are often pushed down because of the way that procurement is set out. With these outcomes, it is no surprise that the biggest concern is around implementation, what you are monitoring with the indicators and how that relates back to the outcomes. Finding mechanisms that relate to something that the Government can do— procurement—which then links to an indicator that you can measure and which relates back to the outcomes, would be valuable and is desperately needed for the NPF as a whole³Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

49. Proposed revisions to the Health National Outcome are as follows:

    National Outcome	National Outcome Statement
    Current Health National Outcome	We are healthy and active
    Proposed updated Health National Outcome	We are mentally and physically healthy and active

50. The Scottish Government states that the proposal to update the Health National Outcome is intended to "better reflect the equal significance of physical and mental health for wellbeing". It also sets out its view that the extended definition, set out in the document, "acknowledges the need for high quality health care and services"¹Scottish Government. (2024, May 1). Consultation with Parliament in connection with the Review of National Outcomes. Retrieved from https://nationalperformance.gov.scot/information-hub/consultation-parliament-connection-review-national-outcomes.

51. Evidence submitted to the Scottish Government's initial consultation highlighted the need for:

    • parity between physical and mental health,

    • higher prioritisation and better support for mental health care,

    • a high-quality healthcare system delivered through a fully supported and resourced NHS, and

    • recognition that healthcare is a lifelong right.

52. Submissions received as part of the Finance and Public Administration Committee’s call for views included calls from various stakeholders for the following:

    • strengthening public health infrastructure and ensuring equitable access to healthcare services across different regions and populations,

    • addressing the commercial determinants of health, such as the availability and marketing of unhealthy food, tobacco, and alcohol,

    • ensuring that mental health is given equal priority to physical health

    • strengthening community health services and ensuring equitable access to care across different regions,

    • a renewed focus on sport and physical activity to be reflected in the Health Outcome, and

    • preventative care as a key focus

53. During evidence, the Committee explored these themes with a particular focus on mental health and preventative care.

54. Stakeholders welcomed the renewed focus on mental health reflected in the proposed updated Health Outcome. The Committee heard arguments that measuring improvements to mental health should not be confined to the Health Outcome alone, a common theme which is discussed in more detail later in this report. Emma Congreve told the Committee:

    Success in improving people’s mental health is a cross-cutting issue. However, because the NPF is set out in portfolios, it feels as though it does not speak to that cross-cutting prevention in any meaningful way [...] It is good that mental health is recognised, but as for where it sits in terms of making progress, it cannot just be measured within the health outcome, and that is quite a problematic feature of the NPF²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

55. During the session, it was noted that mental wellbeing is the only health indicator that has shown declining performance, and that the mental health budget has faced real-terms cuts in recent financial years. Witnesses spoke of the importance of aligning budget decisions to the NPF and argued that the Framework should be "front and centre in budget decisions". This is a theme which is addressed further, later in this report. In relation to mental health, Emma Congreve told the Committee:

    [...] with the decision to cut mental health funding, for example, you would expect to at least see some evidence that, through the decision-making process, there was discussion about, or analysis of, the impacts on the NPF outcome on mental wellbeing. One would like there to be recognition that such thinking played a part. The Scottish Government might produce that information internally, but it is not published. Our worry is that the NPF is not front and centre in budget decisions, because, for it to be valuable, it probably should be²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

56. Contributing to the Committee's 2025-26 pre-budget scrutiny on 3 September, Michael Kellet from Public Health Scotland argued that the planned refresh of the NPF offered opportunities to further prioritise preventative spending within health and social care budgets:

    [...] we believe that the refreshed NPF and emerging legislation such as the proposed wellbeing and sustainable development bill potentially provide a focus on strengthening our collaboration as well as a focus on prevention, so that we can get upstream and make public services—particularly health and social care services—more sustainable in the long term⁴Health, Social Care and Sport Committee. (2024, September 3). Official Report 3 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15970.

    Mr Kellet argued that creating a third category of spending, namely preventative spending, would increase transparency and accountability in relation to budget decision-making on the extent to which preventative spending was or was not being prioritised:

    I think that the suggestion is primarily about accountability. The spend would become transparent to those who run the services, to those who hold them to account and to the public, and it could be tracked over time. That extra category of spending might put extra focus on accountability. I am not pretending that it is the only thing that could be done, but I think that it would be important. There is a point to accountability and to tracking, through a national performance framework, that would measure preventative intervention and support it, and there is a point to public bodies being held to account for their performance on prevention in a way that, largely, does not happen at the moment because the focus is, understandably, concentrated on service delivery. ⁴Health, Social Care and Sport Committee. (2024, September 3). Official Report 3 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15970.

57. When the proposition of creating a third category of spending within Government budgets was put to other witnesses, many were hesitant, partly because, as some argued, defining what constitutes preventative spending would be nowhere near as clear cut as the distinction between capital and revenue spending. Professor Donaldson was also sceptical of the extent to which the current review of the National Performance Framework offered a realistic opportunity to look at ways of prioritising preventative spending on health and social care. He told the Committee:

    I am sorry to sigh, but, every time there is a review like this, it is an opportunity for preventative spend—is it not?— and then that never happens. Then, when we get into dire budgetary straits, it is one of the things that is easily cuttable—a typical false economy, if you like²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

    Professor Collins told the Committee:

    The preventative stuff is important. However, again, the immediate challenge is how one focuses on prevention in the way that one would like to—longitudinally—in the context of resource scarcity. People are likely to have to prioritise what is critical and urgent [...] Of course, prevention is a fantastic thing but, in the current context, it is likely to be deprioritised²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

58. Carol Calder spoke about the work of Audit Scotland and outlined that "many of our health-themed reports have talked about the lack of focus on prevention". She went on to argue:

    I think that that is because of the budget situation that agencies are in. Prevention requires a medium and longer-term planning horizon [...] One of my colleagues says that trying to shift to prevention currently is like trying to overhaul the engine of an aeroplane mid-flight. We need to plan forward. That is not easy, but we need an alignment of policy, strategy and funding and we need monitoring of what works and what does not work so that what does not work stops being done and we focus on what works²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

60. During its scrutiny, the Committee explored the following interrelated themes related to the proposed National Outcomes:

    • Indicators and measuring success

    • Cross-cutting policy

    • Accountability

    • Funding and budgets

    • Public engagement

61. The assessment of performance against the National Outcomes is set out on the Scottish Government's website. The website notes that "Performance is assessed as improving, maintaining or worsening based on the change between the last two data points of an indicator¹Scottish Government. (2024). National Performance Framework. Retrieved from https://nationalperformance.gov.scot/about/what-it ."

62. This SPICe blog sets out information taken from that website to show how each indicator is performing. Table 1 below shows that, as of 4 August 2024, three indicators under the Health Outcome show improving performance, five show maintaining performance and one shows as worsening:

63. During evidence, witnesses raised concerns around how performance against these indicators is measured and reported. Witnesses expressed concerns that measuring progress against the National Outcomes can be challenging, data can be confusing, and that there is a risk that the National Indicators may create a misleading picture.

64. Carol Calder set out her view that outcome indicators do not tell the whole story. Carol argued:

    You have to go deeper and understand what is happening on the ground. That might involve supporting indicators that can give you the picture that you want, but it is also about looking at what works, identifying what works, where the spend has gone, how that public money has been used, and whether the impact can be demonstrated²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

65. Professor Donaldson argued that viewing data without any additional context could be problematic and give a false representation on progress in relation to the National Outcomes:

    [...] if healthy life expectancy is maintained, I am not sure that I would see that as a success because that indicator has improved generation on generation, successively over decades, and has now stalled. If maintenance is the best that we have, I am not sure that that is particularly impressive²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

66. Emma Congreve described challenges around the way performance against the indicators is classified according to the three categories of "maintaining", "worsening" and "improving":

    As an analyst and an economist, I struggle to understand it when we look at the indicators and trends and see definitions such as “maintaining”, “worsening” and “improving”. It is sometimes quite hard to understand how they relate to what is in the graph. There is a lot of work to do to help people to understand what is being measured and why. If there is a change from last year, or no change, it might be statistically robust to say that progress is being maintained. That might be within the margin of error and statistically that is okay. However, from the point of view of somebody who is trying to understand whether Scotland is doing well or not, it does not really help²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

67. Stephen Boyd suggested that, in his view, there was a disconnect between performance monitoring, the NPF and the impact of Scottish Government policy:

    I do not think that the Scottish Government website is fantastic at explaining the changes in performance and, as far as I can tell, it certainly makes no attempt to even attribute successes and failures to the policies of the Scottish Government or of others. That is an issue right across the NPF²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

    He went on to argue:

    [...] there is no connection between performance as currently measured and Scottish Government policy. If the whole point of a NPF is to determine policy, break down siloed approaches and so on, it would be helpful if we could make some connection between that performance and the measures that are currently targeted at improving that performance. Clearly, links to current budget measures or budget spend would be helpful in that regard, but at the moment there is nothing like that on the website, which I think is quite disappointing²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

71. Witnesses recognised wider challenges with the nature of the National Outcomes and their associated indicators and how they may connect or intersect with each other. There was general agreement among witnesses about the current siloed nature of the NPF and the need for links between the portfolios to be improved to enable outcomes to be successfully delivered. Witnesses told the Committee that a lack of joined-up thinking between portfolios can impact negatively on strategic decision making and accountability. This is a theme that is discussed in greater detail later in this report.

72. Speaking specifically on the revised Health Outcome, Emma Congreve told the Committee:

    with so many of the issues that are coming through in physical and mental health, the solutions lie within other areas of the NPF and not within health and social care services, although they have a role, of course¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

73. Carol Calder reiterated this view that the determinants of health span Government portfolios and that joint action and joint accountability are both necessary to make the NPF meaningful and deliverable:

    The determinants of health cut across Government, and one agency cannot deliver all the outcomes in the NPF. There has to be shared accountability, joint activity and joint clarity about how the roles are joined together. We need to look at it holistically. To look only at health spend in relation to the health outcomes gives you only part of the picture. Education, economy and housing all have an influence¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

74. Carol went on to argue that, in her view, different organisations and agencies need to work together more effectively to address these complex cross-cutting issues, and that there was equally a role for cross-cutting monitoring and scrutiny. She spoke of the importance of widening scrutiny in a way that transcends organisational boundaries:

    We need scrutiny that goes across the agencies that are involved to properly demonstrate progress against the outcomes. That is the only way to get the full picture of all the contributions that are being made towards progress¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

75. Professsor Collins expressed his view that the NPF as originally formulated a decade ago may no longer be the most effective mechanism for tackling issues that are cross-cutting in nature, such as the social determinants of health. He told the Committee:

    Health is probably the issue that crystallises the necessity for those perspectives more than any other. At the GCPH, we are not primarily concerned about the delivery of healthcare; we are primarily concerned about health as produced over a longitudinal period by the interaction of a range of social determinants of health, which cut across the full spectrum of policy domains. That understanding is now fairly well assimilated in the policy mindset of Government and local government and a range of other agencies. The challenge now is, on the one hand, to think about the technical and technocratic aspects of policy delivery across policy domains while, on the other, thinking about how we deliver the outcomes of a NPF that was conceived in quite a different time¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

76. Stephen Boyd set out his view that careful design of the indicators underpinning the National Outcomes would be key to successfully breaking down barriers between policy areas:

    If the NPF is working effectively and efficiently, it should be a tool to help to break down that siloed approach. There is a conversation to be had about whether it has worked in that way. I have experience of that from both inside and outside Government. As we move forward in looking at the indicators underneath the national outcomes, a lot of thought needs to be given to how they can be mutually supportive. I have already mentioned the connection between people’s experience of the labour market and health outcomes. It is important to design the indicators to ensure that that is reflected in both strands¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

77. Professor Collins also emphasised his view that maximising transparency in the way indicators were measured and reported, as discussed earlier in this report, would be critical to the National Outcomes and the NPF providing an effective framework for delivering policy improvements:

    [...] to begin with—this goes back to how well we record our progress against the indicators—there needs to be honest, up-front recognition of where we are at and how we got here¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

81. Witnesses giving evidence to the Committee argued for strengthened accountability for delivering the National Outcomes. They also argued for the need for improved mechanisms to ensure that the NPF is more effectively integrated into decision-making processes and actively influences the development of national and local health and social care policies. Stephen Boyd told the Committee:

    I guess this morning’s conversation is taking place based on the assumption that the NPF is the guiding star for public policy in Scotland, but I am not entirely sure that day-to-day practice in the public sector reflects that reality [...] If we really want public sector leaders to grasp the nettle in terms of the national outcomes, a much stronger signal has to go from this place, and from the Scottish Government, that the NPF should, indeed, play that role of guiding star¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

82. Witnesses spoke about an implementation gap in terms of achieving the National Outcomes, where the policy intent behind those outcomes is not being delivered in practice. In order to address this gap, Carol Calder argued for individual agencies to be made accountable for their progress or lack of progress in delivering against the National Outcomes:

    At the moment, there is no clear link to the outcomes for all the different agencies that deliver public services; there is collective accountability, but what that means is that nobody is accountable. There is no clarity on the intended or expected impact of the funding that is given to public bodies, and if there is no accountability, spending happens in a way that is not necessarily aligned with the outcomes [...] what I am trying to say is that the NPF is your vision, or mission, and to deliver that mission, everyone needs to be on the same page. Decisions need to be made with that in mind. That is the ultimate target, and the work that is done should be aligned with that.

    She went on to say:

    If a chief executive of an NHS board or a local council knows that they will be held to account for what they have done to contribute to outcomes and the work that they are doing in that respect, they will corral their information and activity to be able to demonstrate that. What gets measured—and what you are held to account for—is what gets done. I am repeating myself, but we need to require all public sector leaders to demonstrate how they have contributed to the outcomes¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

83. However, rather than a policy implementation gap, Professor Collins instead argued that there is currently a policy formulation gap. He argued that talking about an implementation gap diverts focus from where responsibility should lie and, as a result, fails to deliver the required change:

    It seems to me that the NPF describes policy ambition. Are we doing enough to translate policy ambition into implementable policies that have resources attached to them and which can be delivered by the agencies that we expect to deliver them? That is probably another part of the explanation. This would not be the first time that people have said, “The problem is an implementation gap and the answer is accountability”—and when the next cycle comes around, the explanation is still the implementation gap and the need to hold more feet to the fire. You get a lot of burnt feet, but not a lot of progress¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

86. Witnesses who gave evidence to the Committee questioned the extent to which the National Outcomes in the NPF have an influence on policy-making, budgets and spending decisions by the Scottish Government. They also spoke about the effects of the current adverse economic and fiscal climate and the importance of prioritising spending effectively in that context. In particular, witnesses emphasised the importance of tackling the socio-economic determinants that underlie poorer health outcomes, such as deprivation.

87. Carol Calder made the case for the National Outcomes to underpin all policy and budgetary decision-making, arguing that the two are intrinsically interlinked:

    I think that it comes back to making the outcomes the umbrella under which all decision making is made. It is a case of thinking about what you are trying to achieve in your decision making and how that will deliver the outcomes. It is a question of making a clear connection between the decisions that you take and the outcomes. We are not in an environment in which all those outcomes can be improved all the time, so, as my colleague Professor Collins said, it is a question of prioritisation. We need to think about what we are trying to achieve. If we salami slice the budget without thinking about the impact that that will have on the outcomes, we are missing a trick. There will be a disconnect between what we are saying we want to achieve as a country and how we are delivering that. This is really hard to do, but I think that the outcomes need to be considered as part of the decision-making process. We need to be transparent about the fact that the decisions that are taken will mean that we have to prioritise one thing against another. If we try to go forward on all fronts when we are fiscally constrained, perverse and counteracting actions will end up being taken by different parts of Government. Therefore, it is a question of creating coherence, and the outcomes give us the framework to do that¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

88. The need for improved transparency of decision making, particularly in relating budget decisions to the National Outcomes was emphasised in evidence to the Committee. Emma Congreve set out her view that it can be difficult to see where money is being spent in the Scottish Budget and emphasised the importance of linking spending decisions to the NPF in order for the NPF to be a meaningful tool for driving policy change:

    Being able to pin things through to the NPF is quite a challenge, but with the decision to cut mental health funding, for example, you would expect to at least see some evidence that, through the decision-making process, there was discussion about, or analysis of, the impacts on the NPF outcome on mental wellbeing. One would like there to be recognition that such thinking played a part. The Scottish Government might produce that information internally, but it is not published. Our worry is that the NPF is not front and centre in budget decisions, because, for it to be valuable, it probably should be¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

    She went on to argue that making these connections would make the NPF more than just a "statement of intent":

    It is feasible to align all the Scottish Government’s spending lines with the outcomes, and that would be incredibly helpful. It would help with budget transparency, and it would make the NPF more meaningful as a way of holding the Government and other parts of the public sector to account¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

89. Professor Donaldson spoke of programme budgeting and marginal analysis (PBMA) as a framework for driving the most efficient use of finite public resources. He described the concept of PBMA as follows:

    Programme budgeting is just a statement of where we are now in terms of how we are spending our resources. It is completely unthreatening—it is just saying how we currently spend our resources. The marginal analysis bit [...] then leads us into thinking about how we might move those resources around to get more benefit in total¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

    He went on to suggest that developing a programme budget would be helpful in determining a clearer link between particular budget decisions and progress towards meeting certain National Outcomes:

    What is the requisite spend in relation to the different indicators in different parts of the public sector and the economy? Can we divide that spend according to other key aspects, such as population demographics and geographical areas? Can we—to use the example that I gave earlier—try to match local NHS expenditure with data on mortality rates? Are we spending more in better-off areas and less in the more deprived areas? If that is the case, what can we do, using marginal analysis, to move resources around in order to improve the situation? There is a lot of potential in having a set of programme budgeting data that goes along with the set of indicators underlying the framework¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

90. Professor Donaldson went on to outline actions that, in his view, could be taken to align budgets and the National Outcomes at national and local level, highlighting the particular importance of aligning the NPF more clearly with the commissioning and procurement practices of Integration Joint Boards (IJBs) in this regard:

    If it was possible, we could have, along with the framework, an accompanying programme budget exercise. That would mean that, along with the framework, the outcomes and the indicators, we would have a budgetary system that related to the indicators and the outcomes. That would be done at the national level. At a more local level, where decisions about resources have an impact on people’s lives, I am not sure that there is a particularly strong incentive for IJBs, which have been referred to, to comply with or participate in the idea of a NPF in relation to how it will impact their planning and commissioning rounds. There is a disconnect, so we need to think about how we can create incentives so that the performance framework is not just at the national level. It should be aggregated from the local level up to the national level¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

91. When asked how current spending could be better tracked in terms of its contribution towards meeting specific National Outcomes, Emma Congreve argued that existing data could be repackaged in a way that would enable this to happen¹Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024]:

    The Scottish Government has to report to the Treasury on spend in particular areas, which is done by a series of conventions according to which category it is spent under. You can see some of these programme spend totals coming out through Treasury documents, which are called the “Public Expenditure Statistical Analyses” statistics. That also comes through into “Government Expenditure and Revenue Scotland” in some respects. Some of the plumbing is there for pulling the figures into meaningful categories of spend that you can track over time, but they are not routinely put in front of the Scottish Parliament.

    When we come to look at the budget each year, we see the previous year’s budget, in terms of what was put in it, and we see the budget for this year; we do not have another column that shows what was spent in the previous year. However, from our understanding—again, this is Fraser of Allander Institute analysis—that would be feasible, but it is not being done routinely. I will not say that it is an easy win, because these things are never easy, but it is possible. It would probably bring us a bit more up to the level of reporting that the UK Government does around some of these things.

    We can say a lot about local government accounting being done unhelpfully, but local authorities report back every year. Local government finance statistics come out every year showing what they are spending on every area. The Scottish Government is almost a bit of an outlier in not having the same level of routine reporting back to the Scottish Parliament on what is spent year to year. That data will be buried somewhere, but it should be brought it to the surface.

96. During evidence, the Committee explored the role that the public play in shaping the development of the NPF, and how public engagement in setting national outcomes could be improved.

97. The written response from Oxfam Scotland expressed the organisation's disappointment at the "highly limited level of public engagement undertaken during the review process¹Oxfam Scotland. (2024). Response to the call for views on the National Performance Framework: Inquiry into proposed National Outcomes. Retrieved from https://yourviews.parliament.scot/finance/proposals-for-revised-national-outcomes/consultation/view_respondent?show_all_questions=0&sort=submitted&order=ascending&_q__text=oxfam&uuId=219850182 [accessed 17 September 2024]".

98. Witnesses giving evidence to the Committee emphasised the importance of having a good understanding of public and community perspectives to inform the National Outcomes and that the Scottish Government should have associated mechanisms, policies and programmes to achieve this. Professor Collins told the Committee that more engagement was needed, alongside specific actions to increase public awareness, understanding and capacity to engage. He used the concept of a 'wellbeing economy' as an example to illustrate his argument:

    I think that this brings us back to an earlier question: do people know what a wellbeing economy is? If they do not, whose fault is that? Whose job is it to strike up that dialogue and establish that relationship between what the Government is trying to do and what people are actually talking about? A wellbeing economy does not seem to me to be something that would be a particularly hard sell for a great majority in society to understand and commit to. All we have to say is that, instead of pursuing GDP and numbers, we are going to run the economy in a way that supports and delivers wellbeing, greater equality and greater happiness. It is all about trying to crystallise for a wider public the actual relevance and value of these discussions and to invite them to join the discussion in ways that are meaningful and accessible. I am not exactly sure how you would do that, but if there were some concerted attempt, I guess that we would learn from it and might do it better in future cycles²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

99. Witnesses also pointed out that responses to the Scottish Government's consultation on the NPF were almost exclusively from those who already engage regularly. Stephen Boyd argued that a more participative approach to public engagement was needed:

    Something that I was struck by when I was looking through the documents over the past couple of days was that there does not seem to have been a huge effort to engage the public on this. Most of the organisations that responded were the usual suspects that respond. If you are going to have participative democracy— and if you are going to do it well—you need to understand it, you need to be creative and you need to spend a bit of money, too²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

100. Emma Congreve highlighted the need to engage with more 'hard to reach' groups that do not regularly participate in consultations:

     It is hard to do, because you can do public consultations and get lots of responses, but if you want to find out the views of more disadvantaged communities or people who do not routinely engage in political debate you need to put a lot of resource, time and effort into finding those views²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

     She further argued that there was also a need to "close the feedback loop" by updating organisations, communities and the public on the changes to the National Outcomes and the NPF that have resulted from their engagement.

101. Professor Donaldson also suggested that undertaking qualitative research could help to provide a better understanding of people's value systems and priorities and to reach more people:

     There are quite systematic ways of doing that through more qualitative research. Without getting into it, a method—Q methodology—that is promoted by a colleague of mine, Professor Rachel Baker, is really good at finding out what people’s underlying value systems are with respect to these thorny issues, and it can help with the participation of the hard-to-reach groups to which Emma Congreve has referred²Health, Social Care and Sport Committee. (2024, September 10). Official Report 10 September 2024. Retrieved from https://www.parliament.scot/api/sitecore/CustomMedia/OfficialReport?meetingId=15989 [accessed 17 September 2024].

11th Meeting, 2024 (Session 6), Tuesday 16 April 2024

3. Scrutiny of proposed National Outcomes (in private):

The Committee agreed its approach.

23rd Meeting, 2024 (Session 6), Tuesday 10 September 2024

2. National Performance Framework: Proposed National Outcomes:

The Committee took evidence from—Emma Congreve, Co-lead, Scottish Health Equity Research Unit;Professor Cam Donaldson, Professor of Health Economics, Glasgow Caledonian University;and then from—Carol Calder, Audit Director, Performance Audit & Best Value, Audit Scotland;Professor Chik Collins, Director, Glasgow Centre for Population Health;Stephen Boyd, Director, IPPR Scotland.

Sandesh Gulhane declared an interest as a practising NHS GP.

3. National Performance Framework: Proposed National Outcomes (in private):

The Committee considered the evidence it heard earlier under agenda item 2.

• Tuesday 10 September 2024: evidence from stakeholders;

The The Finance and Public Administration Committee received the following written submissions to its call for views as part of its inquiry:

• Published responses

The Scottish Parliament Information Centre (SPICe) produced a summary of the written submissions received to its call for views. The summary can be viewed at:

• SPICe Summary of Written Submissions