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Chamber and committees

Health and Sport Committee

Meeting date: Tuesday, September 19, 2017

Agenda: Subordinate Legislation, NHS Governance, Draft Budget Scrutiny 2018-19


Draft Budget Scrutiny 2018-19

The Convener

Under agenda item 2, we have two evidence-taking sessions on the draft budget 2018-19. We have less than an hour for the first panel, so I welcome Andrew Strong, assistant director of the Health and Social Care Alliance Scotland, also known as the alliance; Aileen Bryson, interim director for Scotland of the Royal Pharmaceutical Society; Richard Meade, head of policy and public affairs at Marie Curie; and Carolyn Lochhead, public affairs manager at the Scottish Association for Mental Health.

We will move directly to questions.

Alison Johnstone

There is a view that integration is making the delegation of funds complex and making it difficult to assess whether the allocation of the health and sport budget meets the Scottish Government’s stated priorities. In the submissions that we received, Marie Curie noted that

“no additional or specific financial resource has been committed to”

supporting the commitment in the Scottish Government’s health and social care delivery plan to doubling palliative and end-of-life provision in the community and that integration joint boards are expected to meet that from within their own budgets; and SAMH noted confusion over the allocation of new mental health funding and that

“publicly available detail”

on spending

“varies greatly between IJBs.”

Is the available information on the health and sport budget adequate and detailed enough? What would support better scrutiny?

Richard Meade (Marie Curie)

The health and social care delivery plan, which was published at the end of December 2016, was really welcome, particularly the commitment to doubling the palliative care resource in communities. Unfortunately, we have seen no sign of any additional resource for that. We have been told that integration authorities are expected to find the funding from within their own resources but, having engaged with 30 of the 31 integration authorities, we are not entirely clear where palliative care sits in their priorities. A cursory glance at their strategic plans shows that many of them do not even mention palliative care, even though we know that it is a national priority.

A letter to integration authority chief officers from the Scottish Government, dated 15 December 2016, listed palliative care as the second priority, but it cannot always be seen in authorities’ strategic plans. There is not necessarily any evidence of resource being put into it, and we are yet to see any really strong movement on the ground to match that national intent and ambition.


Aileen Bryson (Royal Pharmaceutical Society)

I have a general point. We lobby and advocate for changes where we feel that the pharmacy profession can make a difference to patient outcomes and where there is space for more efficient use of NHS resources.

All that the draft budget can tell us is where there has been an uplift; it cannot tell us whether any of that uplift will be spent in any of the areas in which we have made recommendations for positive change. We can make comparisons—from the old draft budget, we could see that the only body among the four independent contractors that does not have an uplift is pharmacy, so the organisation that does our negotiations would probably question that—but it is much easier for us to track progress if money is allocated to a particular workstream. For instance, the new money that is being allocated for three years for pharmacists in GP practice has now been baselined so that we can see where that has gone. That will be helpful, but the budget is not particularly transparent.

Carolyn Lochhead (Scottish Association for Mental Health)

We see very different levels of detail in IJBs’ reporting on and plans for mental health. It is difficult to compare, because the structure is not consistent across all of them—it is hard to see what is going in where. At national level, we welcome the £150 million investment that has been announced for mental health, but we have found it difficult to follow that from the first announcement to the more recent announcements about what it will be used for, how much has been allocated and how much has not. At IJB and at national levels, we could do with more clarity and transparency.

Andrew Strong (Health and Social Care Alliance Scotland)

I agree with all the points that have been made. We are one year into the integrated systems and we know that there is some good partnership working between the third sector and the IJBs, not least through some of our members such as the Red Cross, the Food Train and the Royal Voluntary Service. Given the financial pressures that are being felt by IJBs and the rebalancing of some of the investment in primary and social care, it will be a challenge to support and protect preventative work, which is largely delivered by the third sector. The integrated care fund is one element and, in advance of this meeting, I tried to find out what integrated bodies have used that fund for. The information was patchy—there were different approaches to making available information that I would be interested in, about how they have invested that money, which organisations have benefited and what the outcomes have been.

When the health and social care delivery plan was published, it was made clear that a financial plan would be made available. I am not aware that it has been, at least not publicly. Perhaps the committee could clarify that with the Scottish Government.

Alison Johnstone

A recurrent issue has been the mismatch between local authority and health board budget-setting timeframes. The Convention of Scottish Local Authorities has suggested that those should be brought more into line, and the Pain Association Scotland has said that the misalignment causes real difficulties for

“commissioning ... services from the Third Sector”.

Have panellists found that to be an issue? Do they understand the reasons for the mismatch and why it cannot be resolved?

Richard Meade

The vast majority of our contracts with NHS boards are three-year, long-term contracts, so we are on the point of negotiating our first round of contracts with integration authorities—that will happen over the next year. Until then, we will not really know whether there is a problem and whether the process works. Once we are through that first round, we will have a good idea of how well integration authorities are working with the bringing together of health and social care budgets and new routes for commissioning.

Alison Johnstone

Audit Scotland has suggested the benefits of longer-term budgeting. Richard Meade mentioned three-year contracts, which are clearly longer than some of the opportunities that witnesses will have had in the past. Does a short-term focus inhibit the transformational change that we would like to see?

Carolyn Lochhead

A short-term focus is really difficult, particularly for the third sector. We have contracts of various different lengths. If we have one-year contracts, it is really difficult to attract and retain staff. Short contracts are really difficult for staff to work under—they make it difficult to plan ahead—and it is hard for the people who are using the service to feel safe and secure and to understand the plan. Longer-term planning would help across the board and is much needed.

Richard Meade

I agree with Carolyn Lochhead. We are fortunate in that the vast majority of Marie Curie’s contracts are at least three years long, but on occasions when we have had 12-month contracts, we have experienced the same issues around recruitment and retention of staff and being able to deliver the service to meet our desired outcomes—often it is unsatisfactory for us and for those who are commissioning the service. Long-term contracts are much more successful because they allow us to invest in staff and to innovate, which is crucial as we move away from investing in acute services to investing in the community. Under long-term contracts, we have more time to innovate, develop, redesign and invest in services as we go along. Under short-term contracts, we are almost firefighting from the beginning in terms of how we keep the service going, retain our staff and recruit staff to replace those we have lost because they needed more job security than a short-term contract would allow.

Long-term contracts are the way to go. The whole third sector welcomed the commitment in the programme for government to third-sector contracts being at least three years long—I say “at least”, because longer would be even better.

Aileen Bryson

I agree with that. It applies not just to the third sector, but across the NHS. Sustainability always comes up as an issue. Three years is better than one, but as you get towards the end, even three years is a problem. The issue is not an easy one to address, but in general strategic terms, we need to be thinking much longer term. Pilot projects are carried out and then there is no transfer to a long-term contract—or even one for a year. That impacts on getting the right staff and retaining them. The impacts are vast and cut across everyone.

Andrew Strong

I repeat Richard Meade’s point. The issue is significant for the workforce—if you have a one-year funding model, within six months you will be needing to renegotiate. Before the meeting, we were talking about the particular implications that that has for people who work for third sector organisations; they face a challenge in deciding whether they can continue to work for an organisation or need to look for somewhere where there is more certainty about the future. There could also be implications for the Scottish Government’s workforce plan around social care, given that £850 million-worth of social care is provided by the third sector. There might need to be some sort of recognition that people who work for third sector organisations that provide significant levels of social care will need reassurance about the future of their jobs.

The Convener

On the transparency of the budget, the Scottish Government is involved in a transnational open government programme and I would have thought that being able to understand the budget is a key aspect of open governance. Could the people who use your services pick up the Scottish Government’s published budget and understand whether the money that is going into services has gone up or down?

Andrew Strong


Aileen Bryson

That is a very broad question. Some people would and some people would not. Some people are good with figures and some people are not. It is a complicated document—my background is not in finance, so I think that it is complicated. How long is a piece of string?

Richard Meade

I would agree. It is not always about how much is being spent on services; sometimes the public will be more interested to know what services deliver, how they could improve their life if they needed to use them and whether they are available.

Providing information around health literacy—helping people to understand what services do and how they support people—is much more important than saying that X is spent on a service and that that has gone up by Y or down by Z.

Carolyn Lochhead

I completely agree with that. I would like people to be able to pick up a Government document and understand the difference that a service has made. In mental health, that information is difficult to find. We do not measure outcomes in mental health; we measure expenditure and other important things, but we cannot tell you whether anyone is any better at the end of their interaction with many of the services, particularly psychological therapies. I know that we are waiting for the results of the review of targets that Sir Harry Burns has been leading. We would like some sort of outcomes monitoring in mental health to be introduced as part of that.

Aileen Bryson

We agree with the point about health literacy. How do we teach our young people about these issues in the early years and education? How do we let people know how to use and how to navigate the NHS so that they can go to the right place at the right time? How do we get people to understand that medicines can cause harm and that there are risks? There is a big piece of work to be done around health literacy, which would feed into what has just been said about how people can understand the outcomes and the services that are provided. There is not a clear understanding of that in general.

Andrew Strong

I think that I can go a bit further than the glib answer that I gave earlier.

The committee has asked the IJBs about linking budgets to outcomes, which is important for what needs to be done in the future. I understand that the review by Sir Harry Burns, which will be published in a couple of weeks, will address outcomes and targets in a bit more detail. That gives us an opportunity to consider the indicators around some of those outcomes, particularly the national health and wellbeing outcomes, which were being drafted as the policy was developed. The guidance always said that the indicators underneath those outcomes were a work in progress. In our view, they do not provide a comprehensive set of indicators for the national outcomes—for example, whether health and social care partnerships contribute to the reduction of health inequalities is judged by premature mortality rates and emergency admission rates, when a more complex understanding of outcomes is probably really what is needed to understand where investment is going and what difference it is making.

I have a specific question for Carolyn Lochhead. Your submission mentions the King’s Fund’s document about mental health’s share of expenditure in NHS England. What does that budget cover?

Carolyn Lochhead

That is the NHS budget for mental health expenditure in England. I think that the subtext of your question is, are we comparing like with like? The answer is that it is hard to know.

It would be helpful if you could tell us whether we are comparing like with like—obviously, that is what the committee would like to do, and that is what we are talking about today.

Carolyn Lochhead

We have said that it is difficult to compare IJB budgets and other allocations. It is also difficult to compare expenditure across Scotland and England. Without a detailed knowledge of both systems, it is hard to say absolutely that we are comparing like with like, but I have no reason to think that what is covered is dramatically different. That is why we provided the information, but it is one point of reference and clearly you will want to consider other points of reference in relation to how Scotland is doing on its mental health budget. For example, we know that the budget share has started to reduce in the past year.

Clare Haughey

What do you understand the figures from England to cover? Do they cover the whole of mental health services including primary care, child and adolescent mental health services, infant mental health services, services for older adults and so on?

Carolyn Lochhead

My understanding is that the figures cover the majority of NHS mental health services in England. I do not know whether they cover all of the services, all the way through the age ranges. I would need to check that and get back to you.

That would be helpful. It would be helpful to have a comparator and to see whether we are discussing community mental health, tertiary services or whatever.

Carolyn Lochhead

I undertake to do that.


Brian Whittle

I think that my belief that the preventative agenda will be delivered primarily by the third sector is fairly well known. That gives the Government a challenge, because it is the predominant funder of the third sector. How can the third sector better align itself so that third sector organisations work in partnership with each other in delivery of the preventative agenda, and thereby make it easier, if you like, for the Government to fund them? Where do you currently sit on our being able to fund the preventative agenda properly?

Carolyn Lochhead

There are already some good examples of partnership in the third sector—for example, the work of the alliance, which many of us are members of, and other ways in which we work. It can be very challenging to work in partnership, because in social care commissioning—in which many of us work—the prevailing model is competition: tenders are put out and contracts are awarded. That pushes us down the road of competing with one another.

We would very much welcome examination of how we can commission and develop services in a different way so that we can work in partnership with each other. Nonetheless, I would say that we work in partnership fairly well, but it would be good to look at how preventative services are being commissioned and to ask whether they are being commissioned in a way that makes it possible for us to work in partnership. I would turn your question round slightly and ask whether we can look at the commissioning process and establish whether it supports partnership working.

Richard Meade

I agree. The integration agenda provides a real opportunity to treat the third sector as a genuine partner in partnerships’ strategic commissioning plans, and to bring us to the table as soon as partnerships start considering their plans for how, for example, they might deliver palliative and end-of-life care services. Do partnerships involve all the key players from the third sector and do they bring us to the table so that we can come up with plans together? If they do not, the statutory partners might decide what is to happen and then bring in the third sector later, saying “This is what we’ve got. How can you help us?” Involving us and other relevant partners as early in the process as possible is much more likely to lead to genuine partnership working—not just among third sector organisations, but between the third sector, the statutory sector and the independent sector.

Andrew Strong

I echo colleagues’ comments. One of the committee’s previous evidence sessions discussed the Christie commission and the 40 per cent potential saving that it reported could be made through preventative investment. There is currently significant demand on services—many of which are provided by third sector organisations—which is not being met completely. We are therefore likely to see organisations such as the brilliant Good Morning Service, which is an alliance member, providing services that relieve pressure on health and social care partnerships.

One of the things that I want to push back to the committee is that the 40 per cent saving that is mentioned in the Christie commission report is admirable, and we need to work towards achieving it, but there is a need alongside that to reinforce the point that people need to be involved in design and delivery of services rather than forced into predetermined systems. I am not convinced that we have yet made enough effort on that side of things. There has been investment in preventative services, but we would like more work to be done on how people can shape services, whether through participatory budgeting or other models. I know that some health and social care partnerships are doing that already.

I contend that the committee’s report on work with IJB stakeholders, which came out last week, probably reinforces that need, to some extent. We need to see the bigger picture rather than just take the view that if we invest here, we will save there.

Aileen Bryson

That is a very valid point, but true partnership working is very important. We cannot look at just the third sector; there has to be partnership working. There is huge untapped potential for public health and prevention work in the NHS working with the third sector. Therefore, I would not like the question to be thought of in terms of the third sector alone, although I understand where Brian Whittle is coming from and I completely agree on the social prescribing exercise. However, we should look at the principles of realistic medicine and the themes that have come through about how the NHS has to change. That means that absolutely everybody has to be involved in order to get traction in the preventative agenda.

Brian Whittle

I will just go back over something. Carolyn Lochhead highlighted competition for budget in the third sector. In fact, it is not just in the third sector, because the budget is almost siloed between the NHS and the third sector. Aileen Bryson made a good point that the issue is much bigger than the third sector. However, some organisations in the third sector deliver similar outcomes and compete against each other. Although third sector organisations need to ensure that they are properly funded, do you not also need to ensure that you align yourselves so that it is easier for the Government to fund you?

Aileen Bryson

I will shut up and leave my third sector colleagues to answer that one.

Carolyn Lochhead

We work jointly wherever we can and where the process allows us to do that. However, I come back to the point that it is down to the commissioning process to make it possible for people to work together, and to ensure that commissioners do not fund the same outcome multiple times.

Of course, there are different ways of looking at the commissioning process. In some areas, we have moved away from the traditional commissioning model and now have self-directed support, through which it should be possible to fund a number of providers to achieve a person’s outcomes. That is a good example of where we could see change and a slightly different approach in order to recognise the importance of mental health. We know that people with mental health problems account for about only 5 per cent of self-directed support payments, so we could look at how we invest more in that side of the system so that people’s outcomes, which are of course the most important outcomes of all, are being achieved.

Richard Meade

It is worth highlighting that there are lots of examples of good practice in which third sector organisations work in a complementary way and in partnership—certainly among those of us who work in palliative and end-of-life care. Through the Lothian palliative care redesign programme, our Marie Curie hospice in Edinburgh works closely with St Columba’s Hospice to ensure that we provide city-wide hospice cover. The two often speak and share information and, potentially, work on the same referrals to ensure that people get the right care. There are lots of good examples, but as Carolyn Lochhead said, we have to go back to commissioning arrangements and to have early conversations between commissioners and potential partners about delivering services.

Andrew Strong

There are examples outside health and social care that we can look at. The employability programme, for example, is in the process of being commissioned, and a number of third sector organisations are coming together to make bids separately from each other. Organisations are working closely together on that, so there might be lessons for health and social care from how that commissioning process is being managed.

Maree Todd

As you guys were speaking, I thought about an example that I came across in the past couple of weeks of precisely the sort of partnership and collaboration that you are talking about. There is a palliative care pharmacist on Skye whose post came about because of collaboration between a statutory organisation, industry and the third sector—the NHS, Boots the Chemist Ltd and Macmillan Cancer Support. That is not the only such example that I have come across in the Highlands; we tend to get cross-sector working in the area. Are we ahead of the game, or is that happening all over the country?

Aileen Bryson

Similar work on palliative care has been done in Glasgow; I am not sure who followed who on that, although the Highlands are ahead of the game, in that what you describe is not happening across the country. I think that we would all agree that that theme applies to everything.

We have pockets of really good work, which we want to be translated into something national. We need to get the data and the outcomes and then take forward that good work. It would be really useful if there was something in the budget that translated to that, because the outcomes from that project in Glasgow are fantastic for individual people—it is very person-centred. We hear about district nurses, but we do not have district pharmacists. However, in that project it was almost like having a district pharmacist who followed patients to where they needed help; it was a good example of cross-sector working. Models like that for various therapeutic areas would be an excellent way of bringing in the third sector and having partnership working.

Maree Todd

When the general public are asked about palliative care, they say that they do not want to die in hospital. However, that is still what happens in a large number of cases. Is there any shift in direction in that respect?

Richard Meade

That is absolutely right. We know from evidence that every year about one in four people who needs palliative care while they are dying misses out on it, and we know that just over 50 per cent of people die in hospital, although the vast majority of people would like to die at home or in the community. We therefore know that there is a great deal of work to be done.

The Scottish Government has an ambitious commitment that by 2021 everybody who needs palliative care will have access to it. We have talked about the commitments in the health and social care delivery plan, but we lack the data and evidence at the moment to show what progress we are making towards achieving that vision and ambition. I know that the Scottish Government is committed to developing better data to support palliative care, but it is not just a palliative care issue; we need better data on whether people’s outcomes are being achieved, whether our investment in services and policies is delivering on the ground and improving people’s lives, and whether we can see trends in that progress. At the moment, we do not see in that in palliative care. We know that one in four is missing out and that more than 50 per cent of people are dying in hospital. We need to see data that shows that the situation is improving and that there is progression.

It is not just about outcomes, though. It is not necessarily fair or true to say that someone who has died in hospital has had a bad end-of-life experience. We also need to capture information about quality of care and people’s personal outcomes, given that some people want to die in hospital.

I am sorry, but could we stick to the budget issue, please?

Richard Meade

I am sorry.

Jenny Gilruth (Mid Fife and Glenrothes) (SNP)

I will follow up on my colleague Brian Whittle’s line of questioning about engagement. Community Pharmacy Scotland has said that the new health and social care partnerships

“are still working through how best to engage and manage their budgets and are finding this challenging. Equally we find it challenging to engage.”

Has that been your experience of engagement? Do you know whom to go to and speak to?

Richard Meade

I would say that the situation has improved over the past 12 months, but it has been a real challenge. As I think I said previously, Marie Curie is present in 30 out of the 32 local authorities and we have struggled to engage. A colleague has said that last year we did not even know whom to ask. At least we now know whom not to ask.

The situation is getting better, but it is quite a challenge to find the right person. The partnerships are still trying to work out internally who sits where in terms of commissioning budgets and commissioning plans. As I said previously, the proof will come when IJBs start to commission services that are on existing contracts. Perhaps in 12 months it might be worth the committee’s while to look at how service level agreements have been developed with integration authorities, especially with the third sector, and how they are working out. That would be a good line of inquiry.

Carolyn Lochhead

I agree with that point, because we are still seeing how integration is going to work out. There is a specific point around the third sector interfaces, which exist in each IJB area and have the role almost of representing the third sector in that area to the IJB. That is a very challenging role for anyone to undertake. To take the views of the entire third sector, which does many different things at many different levels and scales, and represent those in a meaningful way, is extremely challenging. I agree with what Richard Meade said about the difficulty in knowing whom to go to and how things work. There is a particular third sector angle to that.

Andrew Strong

On the back of that, I will say that I have made the point to the committee previously that the third sector interfaces are not well funded to do that role. That means that a lot of work is not getting representation at IJB level, whether it is local work or national third sector organisations that are working in particular areas. There is something to be looked at in terms of their capacity building.


Colin Smyth

All your written submissions make quite strong pitches for additional investment in particular areas. Marie Curie obviously emphasises

“the need for ... investment in palliative care”,

while the Health and Social Care Alliance argues for more “investment in social care”. SAMH refers to psychological therapies and the pharmacists have highlighted the importance of the roll-out of the minor ailments service. Does the health service make sufficient use of evidence when it is making budget decisions?

Andrew Strong

That is an interesting question. In that respect, I should flag up some work that Glasgow Caledonian University is doing just now on developing a framework for making difficult budget decisions in health and social care. Concepts such as health economics, decision analysis, ethics and the law have been integrated to come up with a framework for shifting the balance of care, and it is now being tested with four health and social care partnerships. It will be interesting to look at that work and the recommendations and analysis that result.

Many of our members have described their frustration at well-evidenced activity forming an essential part of health and social care pathways, but not necessarily being reflected in strategic commissioning decisions. Our self-management fund, which amounts to £2 million a year but which could use 10 times the funding, invests in innovative forms of self-management support and in supporting the third sector to work in partnership. It covers a number of different programmes. However, even though those programmes are well-evidenced and have been piloted and had some great outcomes, they are not often funded through statutory resources, and we have long been concerned that good practice emanating from the third sector does not lead to wider scalability.

Carolyn Lochhead

One of the difficulties with mental health is that there is often not a lot of evidence to follow. Earlier, I mentioned the lack of measured outcomes in some areas of mental health. Psychological therapies, which has been highlighted as part of our submission, is a good example of where a great deal of effort has been put in and a lot of very technical work done on setting up new systems to monitor how long people are waiting, and the point at which the clock starts and stops. However, although we know that, nationally, we are not meeting the 18-week target for access—only 72 per cent of people are seen within that time—we do not know whether, after receiving whatever psychological therapy, people feel better. It is quite important to know that when choosing where to put budget.

The improving access to psychological therapies programme in England has a way of measuring recovery rates. The target is for 50 per cent of people to achieve a recovery rate, and that is determined by their mental health being measured as they move through the programme. The programme is on target to achieve that recovery rate. It is the kind of thing that we hope we can move to in order to ensure that the NHS has better outcomes-based evidence on which to make budget decisions.

Aileen Bryson

The fact is that the evidence on this is sometimes difficult to find: I think that the committee would struggle to do so. Even though we have a lot of key stakeholder engagement, it is difficult to find the discrete pieces of work that we know are going on across the country, and there is no real method of bringing all that best practice together so that we can gather the evidence. We lobby for areas in which we know we can make a difference, and it is great when we can engage with the committee and talk about and progress those issues.

Moreover, when we have evidence, it takes a long time to turn it into practice or to take cognisance of work that is going on in other parts of the United Kingdom. For example, we are now going to look at care homes, where we know from evidence from other parts of the United Kingdom that we can make a difference to patient care, and make savings for the NHS.

A jigsaw needs to be brought together. I understand that that is a challenge for the committee: we all find it a challenge in our areas.

Alison Johnstone

The submission from the Royal Pharmaceutical Society mentions funding for pharmacists in general practices and emphasises what a positive step forward that would be. You also say that it is

“nowhere near the level of resource required to provide every GP practice with access to the expertise of a pharmacist as promised by the current Scottish Government in the SNP manifesto in 2016”.

Are you discussing that with the Government and are you hopeful that the proposal will be progressed?

Aileen Bryson

Since we submitted, there is a new document from the Scottish Government called “Achieving Excellence in Pharmaceutical Care: A Strategy for Scotland”. It lays out a lot of the things for which we advocated in our manifesto. Our concern is how that can be implemented and enabled without additional funding. Previous successful strategies, such as “The Right Medicine: A Strategy for Pharmaceutical Care in Scotland” in 2002, had extra funding.

It depends on the wording. We would like to think that people have access to the expertise of a pharmacist. Some members of the committee have signed up to the proposal in the manifesto we had during the Scottish election in 2016 “Right Medicine—Better Health—Fitter Future” on everybody having access to pharmaceutical care. If there is a good local arrangement and people are speaking to each other, GPs and pharmacists can work closely together.

One size does not fit all, and how much access a practice needs depends on its geography and the set-up of the practice. Each general practice is different. We know that the funding is not enough overall even to give a half-time pharmacist to every practice. The original proposal was for 140 full-time equivalents. The Government is working towards that, but we know that it will not be enough.

A lot will depend on expectations. We need more workforce planning and we need a clearer idea of roles and remits and where the Government wants people to work. We know that, if we get the pharmacists in the right places in primary and secondary care, we can make a difference.

Thank you for your evidence. I suspend the meeting to change the panel.

11:22 Meeting suspended.  

11:27 On resuming—  

The Convener

I welcome to the meeting Dr Andrew Fraser, director of public health science, Scottish Directors of Public Health; Kim Atkinson, chief executive officer, Scottish Sports Association; Sheila Duffy, chief executive, ASH Scotland; and Alison Douglas, chief executive, Alcohol Focus Scotland.

We have around an hour for this session. We will move directly to questions.

Alison Johnstone

In order to scrutinise the budget, it is obvious that it has to be clear and accessible. The written submissions suggest that people are not always finding it so. Alcohol Focus has noted that alcohol and drug partnership budgets have become harder to track. The SSA has noted a lack of detail on how the sports budget is allocated. If panel members were listening to the earlier evidence, they will have heard that that was the view of SAMH and Marie Curie too. I am interested to hear from this panel whether the information available on the health and sport budget is adequate or detailed enough.

Alison Douglas (Alcohol Focus Scotland)

As Alison Johnstone has alluded to, the concern about alcohol and drug partnerships funding is that it has always been routed through the health boards. When we saw the significant reduction in funding that happened two years ago, health boards were asked to make up the difference, or at least to ensure that there was no loss of support available to people. Even prior to that, it had been clear that it was extremely difficult to track funding. ADPs would tell us that they did not always have control over the funding that it had been indicated should have been available to them. It has always been the case that that funding should be topped up by local partners, but it has always been difficult to track where it has gone and how much has actually been invested—and more so now that the health boards have been asked to top it up.

As you will know, Brian Whittle submitted a freedom of information request, asking health boards whether they had made up the shortfall. The figures that came back indicated that about half of the health boards had not made up the shortfall, and we questioned the accuracy of some of the figures that we did see. Transparency is an issue.

We strongly welcome the additional £20 million for alcohol and drug treatment that has been announced in the programme for government, although it is not yet clear how that money will be allocated.


Sheila Duffy (ASH Scotland)

The tobacco control budget was fixed for the lifetime of the five-year strategy that was issued in 2013, so it remains fixed for this financial year. In real terms, that represents an on-going decline, and it is less than 1 per cent of the total health budget.

I have some concerns about the fact that the funding for stop-smoking services, which used to come to those services through the tobacco policy budget, is now going into health board bundles that cover a much wider range of issues. It is hard to track the prioritisation at a local level and whether enough information is getting through for the boards to understand what a massive impact tobacco has on health.

Kim Atkinson (Scottish Sports Association)

I suspect that, as was mentioned in the earlier discussion, some people are better with numbers than others, so it can be tricky.

The widest challenge from a sport and physical activity point of view is that 90 per cent of investment in sport in Scotland goes through local authorities. There is continued investment from the Scottish Government. The £2 million additional investment in the current financial year was very well received by our members and, I am sure, by colleagues in the wider area of physical activity and sport. However, understanding the wider contribution of local government is part of the challenge.

Before Derek Mackay made his statement in Parliament on the Barclay review of non-domestic rates, we had a discussion with him about the potential £45 million hit on local sport and leisure trusts that is proposed in the review. There will be a challenge if that comes about. There are a number of parts to that.

A third strand to consider is lottery funding, which makes up a significant proportion of the investment in sport and physical activity in Scotland. That funding is decreasing, which is a further hit for sport and physical activity.

There are a number of challenges in understanding not only what is being invested in sport and physical activity but how other partners contribute. A huge contribution is made by a range of health workers and we think that more could be done in that area, although I am sure that the Government is investing in that workforce. The same is true in active travel. The announcement to double the active travel budget was very well received, and we are optimistic that it signals a move towards prevention, which we have discussed many times. That investment could be replicated in broader sport and physical activity.

There are a number of challenges in understanding what is spent where and how we can maximise the contribution that the funding makes.

Dr Andrew Fraser (Scottish Directors of Public Health)

You will know well how budgets are distributed in the health sector. The overall health budget has been relatively protected, but it is under increasing pressure and areas such as public health are no exception.

It is always quite a challenge to pick out from the global sum that is allocated to health boards and so on how much goes towards prevention—estimates are made in the various submissions that the committee has received—and, within that, how well people use their time or resource for prevention in other activities. For instance, alcohol brief interventions have benefit. They are mainly rooted in primary care and similar community-based settings, and they are a brief part of a wider intervention that people would have on an individual basis with a health professional. However, it is difficult to identify the cost of them separately and, therefore, to provide a cost benefit equation for such things. That is the main point that I would make about the health budget.

I support Kim Atkinson’s point that a lot of public health-related spend is not in the health budget, but relates to how other sectors allocate resources, local authorities being a particular area of interest.

Alison Johnstone

Thank you for all your responses. When Dr Helene Irvine spoke to us a couple of months ago about the preventative agenda, she said that GP funding could be considered as preventative spend—if we funded that service properly it would prevent more acute cases and people presenting at accident and emergency. Andrew Fraser spoke about the difficulty of placing prevention above other services. There is always that tension: we feel compelled to address symptoms, whether people present them at A and E or at the general practice, and that often means that we cannot invest in prevention in the way in which we would like. There have also been some discussions on the need to have more evidence for prevention. The health budget is very demand led, but is there a need for dedicated funding for preventative measures? Are we focusing enough on that or does the funding always tend to get removed and sent to the area of greatest need at that time, for fairly obvious reasons?

Andrew Fraser

The answer is both. Sheila Duffy and Alison Douglas will be able to talk about identifiable funding for various programmes. I go along with Helene Irvine’s general premise that primary care is prevention—if primary care is adequately resourced it prevents the need for secondary care.

Yesterday, Sheila and I were talking to a colleague who works in obesity who said that they get feedback from people in primary care to say that prevention is not part of their task and they just deal with disease. There is a spectrum of perspectives on whether primary care is prevention. That raises the question, what is prevention? Is it primary prevention to prevent diseases from happening, secondary prevention to detect things early and nip them in the bud or tertiary prevention, which is rehabilitation and getting people better from diseases that they already have? I would like to shift towards the primary and secondary end, rather than dealing with the tertiary end, as I am sure that we all would.

When you talk about primary care, are you talking about GPs or about the primary care service? Health visitors are certainly there to carry out preventative work.

Andrew Fraser

I readily admit that. I had GP feedback in mind when I gave that example. There is ring fenced, identifiable investment for health visitors. We were talking to AHPs yesterday. Their contribution to prevention is very energetic, particularly amongst older people. They are looking at much more effective prevention among all age groups right throughout the life course. That is not confined to general medical practice—I would include dentists and pharmacists as people who have a great contribution to make in that respect.

Kim Atkinson

A significant part of our response was consideration of the national performance framework and whether we would make changes to the structure. The idealist in us would say that we do not talk enough about healthier life choices, prevention and increasing activity as part of that. There is something idealistic about the health service role in promoting good health as well as treating bad or poorer health. The notion that as people are living longer, their lives should be healthier and happier is a broad mixture. We can work collaboratively on that.

The previous panel talked about conversations with Sir Harry Burns. When Sir Harry Burns was the chief medical officer he said that the best spend in public health was on sport and physical activity and that the key indicator of life expectancy is how physically active a person is. However, we still do not correlate those when we talk about prevention and health. The programme for government and the national performance framework talk about life expectancy as one of the fundamental indicators in a wide number of areas, but they do not link sport and physical activity to that, despite what the former chief medical officer has said. As ever, the challenge is moving upstream, rather than downstream. We need to work out where we all have responsibility for that.

We are part of a Scottish Government working group that is having some really interesting discussions about who is responsible for helping us to make the inactive active, if that is the biggest benefit. It is certainly not the responsibility of the small £34 million budget called sport and physical activity; rather, I would like to think that it belongs to the breadth of the workforce that Andrew Fraser mentioned.

I know that there has been work on trying to get GPs to add questions when they meet patients. Often, GPs are the people who are most likely to meet the inactive. Patients are asked whether they smoke or drink, but why would it cost more to ask a third question about how physically active they are? Only 4 per cent of the Scottish population know how physically active people need to be for their health. We talk about self-directed care, life choices and what people can do to make changes, but only 4 per cent of the Scottish population know how active they should be to improve their health.

It is not just about the small budget for sport; prevention is about looking at cross-budgeting in a way that we have not seen yet. There are change funds and innovation funds, but I am not aware that a change fund or an innovation fund has been about sport and physical activity. New research always needs to be done, but I do not know who holds the research on that and who is the guru in those areas. Alison Johnstone, who is one of the co-conveners of the cross-party group on sport, will know that Professor Nanette Mutrie will be at the next meeting of that group. She is the United Kingdom’s leading expert on the health benefits of sport and physical activity. A number of people have that information, but we do not pull that information together and really look at it, as we would see it, and see the contribution that sport and physical activity can make.

Sheila Duffy

We know that, in Scotland, 10,200 people die every year from a disease that is caused by smoking and tobacco. We know that those deaths are preventable and that smoking is the major preventable cause of disease that we face. Behind each death, there are 30 or more people living with chronic disabling disease. This is not about this year’s smoking figures; it is about decades-past experience of smoking.

If we are concerned about the on-going sustainability of our healthcare system, we must invest in the future and look at prevention that works. We know that certain measures can be taken in tobacco control that are highly cost effective and which work in reducing smoking rates.

We should also look beyond the figures. For example, many medications are half as effective if the person smokes. Can we routinely advise people to stop smoking in the way that we routinely advise that people should not drink alcohol when they take certain medications in order to make those medications more effective and cut the costs to our health service?

Alison Douglas

At the local level, when there is a discussion in an alcohol and drug partnership about the profile of the prevention, treatment and support services that it undertakes, it is inevitable that the effort will be focused on the treatment services, because they are the principal cost. That is also an historical thing. Up until around 2009, the alcohol and drug action teams—or ADATs—focused on the treatment end. It was only with “Changing Scotland’s Relationship with Alcohol: A Framework for Action” that the emphasis on prevention came into the portfolio. However, there is a patchy effect across the country.

At both the national and local levels, because of the organisation and intensity involved in commissioning and delivering treatments, trying to get that right and having the workforce there to deliver them, it is inevitable that the focus of attention will go on treatments. That is why clear direction needs to be given on what preventative activity local alcohol and drug partnerships are expected to undertake.

An important part of the picture is preventative activity that, in essence, costs nothing. I am talking about whole-population measures. The Parliament has provided leadership on minimum unit pricing but, equally, we need to address marketing and availability, which are the other two highly effective low-cost interventions. They do not cost much, if anything. Perhaps they will cost a court case, but I would hope that you would get the funding for that back when you won it.

Those are the things at the population level that will have the most impact. They are the primary preventative measures, and they have to be part of the mix.

The Convener

Do you have any idea where the Government thought that the alcohol and drug partnerships would find the money to make up what was taken from them? Do they have cash stuffed down the back of the sofa or in piggy banks that they can say they have saved for such an occasion?


Alison Douglas

I understand that the cabinet secretary made it clear to health boards that they were to ensure that there was no reduction in the delivery of outcomes, either by delivering efficiencies or by making up the shortfall in resource. That was the Government’s expectation of health boards.

An analogy would be that, although your wages were reduced, you would continue to provide the same things for your family or your household as you had with your previous wages.

Alison Douglas

I think that this committee knows very well the pressures that health boards are under regarding all facets of what they have to deliver.

I am trying to get at whether that was a credible approach to sustaining services in such a vital area of work as drug and alcohol treatment.

Alison Douglas


Thank you.

Brian Whittle

In its submission, the Scottish Sports Association quotes a Scottish Government document as saying:

“Physical inactivity costs the NHS in Scotland £91 million/year”,

but further on it gives the cost of things including obesity, diabetes, mental ill health, smoking and drinking, and it is the thick end of £30 billion. It strikes me that people with any of those conditions are helped, in part, by being physically active. It is a driver for all of them—if someone is physically active, they are less likely to smoke, less likely to drink to excess, more likely to have control of their weight and less likely to have type 2 diabetes.

If the Government is using the figure of £91 million for the health budget for prevention and sports, is it misaligning where the spend should be? To me, the health budget for prevention and getting people physically active should be about the £30 billion cost of the preventable health conditions that currently exist. Do you agree?

Kim Atkinson

Funnily enough, I am quite keen on that question. Our colleagues at the British Heart Foundation recently commissioned some research—it has not been formally released yet—by Dr Charlie Foster, who is an eminent UK professor in the economics of preventative health measures. That research estimates that £77 million per year could be saved in the Scottish budget through physical activity and sport. However, the researchers have been able to measure against only five health conditions: heart disease, diabetes, cerebrovascular disease, gastrointestinal cancer and breast cancer. It is important to say that the list does not include dementia and mental health. It is well recognised that, if those areas were added, that estimate would be very conservative. The issue will be picked up at the next meeting of the cross-party group on sport, of which I know Brian Whittle is a member.

It is important to understand the economics behind the issue. We know that physical inactivity is the fourth-highest risk factor in global mortality that has been identified by the World Health Organization. We know that there is a 30 per cent reduction in all causes of mortality in people who are physically active, and that physical activity reduces the risk of more than 20 chronic health conditions. We know all that, yet we are still a developed-world nation in which 2,500 people die every year due to being physically inactive.

The question is how we can better align the spend, as Brian Whittle said, but the economics and numbers are just one side. The last time we were before the committee, we talked about making Scotland more active and about how, if we were all 1 per cent more active, we would save £85 million over five years. We would also save 157 lives every year. How do we put numbers on the quality and extent of a person’s life? That is the hard part.

The point that Brian Whittle was making is that it is necessary to understand the integrated nature of prevention and where the responsibility for that sits. When, across the healthcare workforce, people ask, “Do you smoke?”, “How much do you drink?” and, I hope, “Are you physically active?”, there should be a combined answer. It is not about one, the other or the extra; it is about what the whole looks like. We will all benefit, on a population health level, if we understand those interactions. I do not think that we are quite there yet, but the potential is absolutely enormous.

Sheila Duffy

Brian Whittle is talking about the Government spending £91 million in the sports budget and £12.2 million per year in relation to tobacco. However, the question makes me think that we should be spending more in relation to tobacco, because a recent UK all-party group report suggested that such spend would deliver a return on investment of almost 1,110 per cent over five years. We can send you the reference for that.

I am not arguing for sharing the pot; we need to co-ordinate. Brian Whittle has spoken about diseases to which many factors contribute, and all our organisations expend energy on trying to improve people’s health. The cross-party group on improving Scotland’s health: 2021 and beyond, of which Mr Whittle is a member, does that well—it discusses the many non-communicable disease risk factors and how we can learn from one another, join up and share what we do. Many people suffer from multiple morbidities, which we need to work together to address. I do not want to squabble about the cause and who is responsible.

Brian Whittle

You have highlighted what I said. The cost to the Scottish economy of smoking is £0.5 billion; if we were more active, we would save £91 million. I am trying to get at the cross-collaborative function. If we could persuade all the smokers to be more active, it is likely that they would not smoke or drink. That is what I was getting at. When the Government looks at those budgets, it must look at the behavioural drivers of a reduction in preventable health conditions.

Alison Douglas

I do not have the research to hand, but I think that there is some evidence that participation in sport is linked to increased alcohol consumption—

Increased consumption?

Alison Douglas

Yes. I know that Brian Whittle would not be an example of that, but a lot of socialising after sport is alcohol driven. I can look into that and get you some information.

I will come back on that point, if you do not mind. I suggest that alcohol consumption and having a poor relationship with alcohol are not the same thing. I would like your comments on that.

Alison Douglas

I totally agree with that. However, 14 units per week is six pints of beer. I would hazard that a number of five-a-side football players consume that after one game.

We need to have a proper debate about that.

Kim Atkinson

I will leave Brian Whittle, in his wisdom, to have that debate, but it is unfair to assume that the issue is five-a-side football, which is just one of our sports. Huge numbers of people participate in sport, and there are many initiatives such as walking football that tackle a wide number of things. As Brian Whittle has said, sport and physical activity are ways of improving health in its own right, but sport is also a vehicle for assisting people to do a wide range of things. We see that in mental health practices, in work between the Alzheimer’s Society and our members and in the relationships between our members and cancer charities. That point is important, but it is not what I had intended to lead with.

It is important to understand that the cross-budgeting that Brian Whittle spoke about is a big challenge at local authority level. Everybody at national Government level agrees that more could be done; one of the biggest challenges for sport and physical activity is what is done at local authority level. As I said, more than 90 per cent of investment in sport in Scotland goes through local authority budgets. Increasingly, local authorities are running services through trusts, the budgets of many of which are being decreased. Scotland has 13,000 sports clubs—I am sure that many of you have heard me quote that figure before. Many clubs are supported in their work—whether that is sport for its own right or as a vehicle for other benefits—by local sports development officers, who are funded by our local authorities. Every hit to a local authority budget or a trust budget undermines the ability of those clubs to provide their invaluable support.

That support is for two groups of people. The focus to get inactive people to be active is huge—there is a 20 per cent difference between the activity levels of the most active and the activity levels of the least active people. However, just as important, and which we often do not touch on, is ensuring that we keep active those who are already active. Given our ageing society, keeping those people active is—if you will permit me to say so, convener—prevention in reverse. If there is a decrease in the 900,000 people who are currently members of sports clubs, things will start to go the wrong way and we will start to have a less active population. Yes, we must focus on getting the inactive active and on the contribution that everyone can make in that respect, but an equal priority is to keep the active people active throughout their lives and to encourage them by offering a wide range of activities.

The Convener

Given that local government has had £0.5 billion of cuts, I would think that the last thing that it, sports organisations, trusts and all the rest would want is another bill on top of that. What impact is that approach going to have?

Kim Atkinson

There are two points to make in answer to that question. First, as was mentioned earlier and in the previous evidence session, we need long-term budgeting. Although cutting the sport and physical activity budget might seem to be an easy solution today, that will have a strong impact on people’s health in X years. That requires that we understand the evidence that Alison Johnstone mentioned earlier and realise that physical health benefits might take time to appear.

However, the mental health benefits, which were highlighted by our SAMH colleagues in the previous evidence session, will emerge much faster. Given that one in four of us will, at some point, suffer a mental health issue and that 30 per cent of the population are on antidepressants, savings can be made in every possible respect, whether they be financial, in the quality of personal life or whatever.

Secondly, we were really pleased to have a discussion and conversation with Derek Mackay on sport and leisure trusts and business rates before he made his announcement. The challenge with regard to the bill for that, which the Barclay report estimates is £45 million, is significant. Are local authorities likely to say, “Right—if that’s the cut, we’ll put £45 million back into the trusts”? If that does not happen, we might be looking not only at the closure of facilities and clubs being unable to provide somewhere to play or places to enable participation, but at an impact on the many local authority run programmes that help to get people active and provide them with the opportunity to find activities. The report contains an understanding that we need to support community sports clubs, by which our members are delighted. However, although that is really important, if we do not support the work of local authorities and trusts, there will be no facilities for clubs or parks and playgrounds, where many people are active.

It is a big challenge. We are concerned about it, and I know that our Sporta Scotland colleagues are looking at the scale of that work. However, we are pleased that we and our Sporta Scotland colleagues have had discussions with Derek Mackay and that his announcement was about consulting more and understanding inadvertent consequences. We are optimistic that those discussions will continue.

Dr Fraser

I would like to pick up on something that Kim Atkinson just said in order to broaden things out. This is not just about single factors. Many people are more likely to drink more or to be more sedentary than others, but they will usually have a lot of factors in common; a common-factors approach would look at people’s lives.

It is also not about trying to find a single solution—to be fair to everyone in the room, no one is suggesting that there is one thing that will sort the situation. Let me quote a piece of research from the Glasgow Centre for Population Health on the GoWell programme, the main focus of which was regeneration and health. The question that the researchers posed after looking at the data was: what makes people go for a walk? Sport is one thing, but mass activity—even fairly lowly types of activity—is what is going to bring us back from the precipice with regard to health and the health burden.

The answer to the question is that people want to leave a nice, tidy house that they are proud of, go for a walk along a nice, well-kept path where they feel safe, and go to a facility that is not just good but very good, whether it is a sports facility, a shop or a bus stop. Those are the things that make people get up and go, and the components include housing associations, community associations, local authorities, inclusive economic growth policies that have been operationalised into rows of good shops and so on. It is a huge and pressing issue as far as activity is concerned, but it will not necessarily be solved via an identifiable budget. We will need cross-working in that respect.

One thing that has not been discussed so far is where community planning partnerships come into this. Although that might not be a central focus of the Scottish Government, the ability of CPPs to influence budgets and the allocation of budgets at the local level is key to addressing many of the issues that have come up today. How we allocate funds to the alcohol and drug partnerships and to local priorities for physical activity and sport will increasingly be determined by organisations, associations or alliances such as those. As well as their having the ability to make decisions and see them through to the good outcomes that we want to achieve, there needs to be the expectation that they will do so.


Kim Atkinson

Walking is very accessible, obviously. Ramblers Scotland, which is one of our members, has done a huge amount of work, and 7,000 people now access the Ramblers medal routes app, which is a significant number of people trying to find ways to walk a bit more.

It is also important to provide diverse activities, because one sport does not fit all, and we should be proud of the diversity of sports that we have in Scotland.

Of their own volition, a number of governing bodies are working to identify how to enable people who might want to start by walking but who have a passion to do something else to find an activity that has the accessibility that walking provides for so many people plus a different kind of motivation. For example, a huge amount of work has been done on walking football and walking netball, and walking basketball is now being introduced. Sports bodies are looking to see how they can appeal to different people such as those who are motivated by something that is a little bit different, those who like walking in the outdoors—which is great, whether that is for travel or for its own purpose—and those who like a social aspect to sport and to meet and engage with other people. That work is a priority.

Linked to that is the chief medical officer’s “Start Active, Stay Active” guidance, which clearly says that there is a dose-response element to sport and physical activity. Except among older adults, there is a dose response at all ages—the more active someone is, the better the health benefits they will reap from their activity. We need to start people being active, but we also need to focus on keeping active those who are already active.

The health and wellbeing outcomes that have been identified do not currently require the integration authorities to report on their contribution to sport and physical activity because it is not one of the outcomes that they focus on. That is linked to Andrew Fraser’s point.

On the convener’s earlier point, if one of the outcomes was around the opportunities that local authorities have, we would understand better the integration that Brian Whittle spoke about—not only the contribution that they can make but the contribution that we all, collectively, can make as part of that.

Maree Todd

This is a very simple point and its moment has almost passed. As somebody who spent 20 years working as a specialist pharmacist in mental health, my ears pricked up when Kim Atkinson mentioned that 30 per cent of the population takes antidepressants. I understand that the figure is nearer to 14 per cent.

Kim Atkinson

My understanding is that the percentage has increased, but I am now checking the figures. I apologise. You are right—30 per cent of GP consultations are related to mental health, but 14 per cent of the population take antidepressants.

Colin Smyth

I would like to return to a point that was raised by Kim Atkinson about the impact that the Barclay review could have on sport. In your discussions with the finance secretary, have you highlighted the fact that, at the moment, a number of local authorities have chosen not to go down the route of establishing trusts or arm’s-length external organisations? With the establishment of an ALEO, a tax loophole is pursued, and the local authorities that have not gone down that route are currently penalised in that they have to pay rates. Therefore, there is not a level playing field for an ALEO and a local authority. Has that been discussed?

Kim Atkinson

The membership body for trusts in Scotland is Sporta Scotland, with which we had a brief discussion. I know that Sporta has spoken to Derek Mackay, and I am sure that that issue was part of the conversation. I hope that our colleagues at Vocal Scotland—sports colleagues in local authorities—will have had a similar conversation.

I understand why the review said that there is a level playing field and I am not arguing against that. However, there is a halfway house, for want of a better phrase, of the type that has been identified for universities. There are areas of universities that are core business, which they are funded and resourced to do, and there are areas in which they might be competing with a private market. I would like to think that there is a halfway house for local authority sports trusts, which would allow them to say that they are doing fundamental work to help people to be active or more active and to provide vital support around sports development officers, sport facilities and a wide range of other things. Prevention would move into reverse if we were to lose those things. I am not arguing against the level playing field argument—I appreciate that that is someone else’s area and not mine—but we need to ensure that we do not back-pedal and go significantly backwards.

I hope that there will be an opportunity to do something in the forthcoming consultation on water and sewerage rates, which are being reviewed. At the moment, the vast majority of sports clubs are not allowed to access rates relief for water and sewerage because the definition on which the relief is based relates to charities and community amateur sports clubs, and very few sports clubs are either of those. From that point of view, we do not see a level playing field operating for sports clubs. We are having a conversation with the Government in which we are keen to point out that the definition that is being retained in the Barclay recommendations, which we hope that Derek Mackay will continue with, should be adopted in the water and sewerage rates and that that will provide a level playing field.

Colin Smyth

I have taken a careful note of the number of times that you have used evidence or figures to back up your case, and I notice that you all use various figures in your written submissions. Do you think that we use evidence enough when it comes to making decisions on health spending? Given the number of competing interests and the amount of competing evidence, how are we able to make judgments on the basis of that competing evidence?

Andrew Fraser

My part of the clinical specialties is built on the presentation of evidence and we want people to pay due heed to it. There are all sorts of issues with the usability and the quality of evidence. No evidence is perfect, because it does not tell you specifically that such and such a thing will work in a particular context. There is a lot of evidence out there of things that might work, but, in terms of the scrutiny that is required before something can go into public provision, the bar is set much higher for preventative interventions than it is set for clinical interventions—there is quite a bit of evidence of that. The committee will see all sorts of issues around high-cost, low-volume interventions that are of marginal benefit. Those interventions have an opportunity cost because, if you have them, you will not have other things.

The other thing about preventative interventions is that they sometimes involve people’s personal decision making or the decision making of a population, which are areas into which people sometimes do not want to go—certainly, the media makes it difficult to do so.

There is a bit of doublethink about preventative interventions and the evidence relating to them in terms of the desirability, the ethics and the standards by which we measure things. We give those factors quite a hard time. Sometimes, those preventative interventions could be put in the “too difficult” pile, with distinct issues of individual decision making relating to marginal interventions being seen to be easier, although not cheaper, to resolve.

Sheila Duffy

That is a really interesting question, and it is one that we struggle with. ASH Scotland went down the line that evidenced-based medicine was taking and said that published peer-reviewed evidence will give us an objective measure that will enable us to say that we are not basing our view on a few people’s anecdotes but are using data that can be generalised.

Published peer-reviewed evidence is a good foundation for the decisions that we make. On top of that, you have to listen to experience because it takes four years for evidence to get into the public domain and be published and peer reviewed. As decision makers, you will get some good steers on the evidence and how it relates to other evidence from bodies such as NHS Health Scotland.

There is a need to be careful about anecdotal experience. We find that the people who are extremely vocal are those for whom something has worked or those who are being incentivised by commercial interests to put forward the view that something works, whereas the people for whom something has not worked tend to be less vocal. We have seen that in some of the social media consultations that have taken place with the committees. It is an on-going question that we wrestle with, and I sympathise with your position.

Alison Douglas

I would highlight minimum unit pricing as an example of an extremely effective preventative intervention—it is one of the most effective options available to us. However, because it had not been tried elsewhere and because the thinking about its effects was based on extremely detailed modelling, people took a long time to reflect on that evidence and be persuaded by it. As Sheila Duffy mentioned, there are those who are trying to deflect and distract by proposing alternatives such as community alcohol projects, which are invested in massively by the alcohol industry but have been evaluated as providing very little benefit.

On preventative spend, is one of the issues how to quantify the money that will not be spent? How do we get the Government to commit to spend by talking about the money that will not then be spent?

Sheila Duffy

The projections for the increase in dementia cases have not continued on the expected trajectory. The best guess is that it is because of heart health campaigns. It is possible to look at some of the things that have happened and to quantify savings a little bit.

Going back to Andrew Fraser’s earlier point, there is a need to do both: to deal with the immediate stuff and the people who are sick and to say that, if we are interested in the health of our children and grandchildren in Scotland, we have to act now to put in place measures that will have an impact. It is like a small farmer deciding to grow cabbages to feed himself next season but also to grow oak trees because, in 50 years’ time, he will want to build a house.

Dr Fraser

This will not help you at all. However, as Sheila Duffy spoke, I thought about Sir John Crofton, who founded ASH Scotland in the 1970s—he was a respiratory physician of great distinction. In the 1950s, he battled tuberculosis and pretty well conquered it in Edinburgh. He then switched his attention to another wave of respiratory-related illness; as that dwindled but did not go, that was followed by asthma. We are now dealing with the respiratory effects of all sorts of other things, including air quality.

The problem is that if we fix one thing, something else emerges. My health economics colleagues would point out that you cannot necessarily say that, if you deliver 50,000 alcohol brief interventions, you will be able to shut a ward. Other things, which have been waiting in an informal unseen queue to get attention, move into that ward. It is very tough to say that, for a given intervention, you will make a saving of a distinct amount. Costs shift and other priorities need to be addressed.

I am not suggesting that you save money for the NHS. I am suggesting that money can be reallocated to other priorities.

Dr Fraser

The explicitness of that decision making is a big challenge. For a given investment and savings, we want to achieve longer, healthier lives, as Kim Atkinson said earlier—longer lives spent away from requiring costly health care. That may be so, but a lot of people need care because of demography, expectations and technology.

Kim Atkinson

I agree with what has been said, and I do not say that it is easy.

On holistic budgeting, the issue is whether you save by being able to provide healthcare to people who were not able to receive it before or in other areas of the wider budget. People who are more physically active have 27 per cent fewer sick days, performance at work can increase by 5 per cent when employees are physically active and staff fitness programmes can reduce absenteeism by 15 per cent. It all makes us a more productive nation.

The question whether we are saving in terms of the wider health budget is for someone who is better at economics than I am. However, such spend will increase productivity and savings in other areas. If we look holistically at budgets in a way that I do not think we are doing at this stage, there could be savings that make a wider package worth doing.

The Convener

Andrew Fraser said that his specialism was based on evidence. Brian Whittle and I probably come from different places. Brian is talking about individual behaviours driving change, whereas I think that structural change in the economy needs to happen in order to impact on people’s health and wellbeing, particularly in deprived communities. Dr Fraser has spoken about an evidence base. Is there any evidence of significant resource being shifted from areas that are more affluent to areas of relative deprivation in order to bring about the structural change that will impact on people’s health and wellbeing?


Dr Fraser

Kat Smith, who is an academic in Edinburgh, has looked at evidence and the way that we treat it. Because upstream interventions—those that deal with the causes of the causes—are difficult to study, studies of downstream or risk-factor interventions are more numerous. They are more straightforward to do and they find end points such as smoking-related conditions. Such interventions have been much better studied, so the evidence base behind them is much firmer than the evidence base for complex interventions at community level.

A few years ago, Audit Scotland looked at the distribution of primary care services, and dentists and pharmacists came out better than medical services. We have a challenge in skewing the distribution of primary care facilities in the health sector towards people and communities with proportionately greater needs. I return to the point about community-based priority setting and skewing things that way. Earlier, there was a discussion of business rates and whether greater business activity in an area means that there is less need. Skewing resources towards areas where there is greater need is probably about finding where there is less business activity. We need to find structural ways—upstream ways—of diverting resources to the people and communities with the greatest needs. We must keep a very close eye on that. I venture to suggest that the allocation of resources at community planning level might help, but it will not help at a macro level—it is a sort of meso level. We need to do all those things to shift resource towards where it is most needed.

Sheila Duffy

Kim Atkinson talked about releasing equity in other ways, such as through the health of the workforce. One in three adults in the 20 per cent most deprived communities smokes, compared with one in 10 in our 20 per cent least deprived communities. If we could take action to reduce the smoking rate in those 20 per cent most deprived communities by 1 per cent—from 35 to 34 per cent—we would release £13 million a year of disposable income back into those communities, and I am certain that it would not be spent on anything nearly as damaging as tobacco.

Does anybody else want to come in?

I just want to mention that my view is not quite as narrow as you said, convener. I have more of an holistic approach.

I am sure that we will hear your view developing over time, as the rest of the committee has influence over you.

Alison Douglas

One point that we have not touched on is about generating additional income. As the committee will be aware, we had a public health supplement on large retailers that sell alcohol and tobacco, but that has lapsed. There is a strong case for reintroducing something along those lines and not necessarily only for premises that sell both alcohol and tobacco—it could be either alcohol or tobacco as well as both. That would be a way of generating additional revenue that could be dedicated specifically to tackling and preventing health-harming behaviours.

The Convener

Finally, we will take it as a given that you all want more money in the budget process. However, given that we have to report to the Government on the budget, what are your other asks? You can have a minute each.

Dr Fraser

It will take less than a minute. We would like less waste of resource that we devote to marginally beneficial activity.

For example?

Dr Fraser

I am talking about things without a proven evidence base that they work. Alison Douglas and others have mentioned some. There are high-cost drugs for which there is insufficient evidence, or marginal evidence, that they work. People need to be very searching about the quality of evidence behind decisions that are taken to allocate such drugs. The opportunity costs of making such decisions are very major on the comparatively low-cost prevention programmes that we have been talking about.

If the areas that you have mentioned are in common parlance among your peers, it may be worth while forwarding them to the committee in order to identify specifics. That would be helpful.

Dr Fraser


Kim Atkinson

I have a couple of things, convener. In sport and physical activity, we talk about “spin”, but there is also a language that is a culture of investment, which is exactly the point that Sheila Duffy made earlier, and which would be across prevention areas. We see local authorities and leisure trusts being tasked with income generation. Surely the point is that anybody who is being active in that way is an investment, so we need to look at the language around that. There is a focus on helping to keep active people active. Because we have an increasing and an ageing population, maintaining our levels of physical activity and sport means that we are increasing them, if that makes sense, so that is a win and there is recognition there.

Our members always talk about physical literacy. To return to education, which I know was raised with the committee before, that is not just about the number of hours of physical education but about young people coming out of school and being physically literate so that they are then able to be healthy in whichever way they choose through sport and physical activity throughout their lives.

When the Scottish Government was reviewing the national performance framework, we had a conversation with it in which we said that it is all well and good to look at each indicator in its own right, but asked where we should look horizontally at opportunities for working more collaboratively. Whether that is created by extra budget facilitation or is just better spend, we could do more of that through a range of areas.

Lastly, in the previous session, the topic of sustained and longer-term investment was raised. Many organisations work on annual budgeting. It would be a fascinating exercise, across the voluntary sector—and, I am sure, other sectors—to understand how much time is spent trying to work out next year’s budget and where it is coming from, when we could be far wiser in spending our budget if we could identify our priorities and provide sustained and long-term investment in them.

Sheila Duffy

I have three points. I would like us to ensure that we maintain targeted stop smoking support, particularly for communities where smoking rates are high, such as among those with mental health issues, in prisons—where we aim to go smoke free—and in our poorest communities. I would like that to be backed up by the mass media, to encourage the whole population to quit smoking, because we know that 67 per cent of adult smokers wish that they were not smokers.

We should also remind people that second-hand smoke is toxic and encourage smokers to take it outside the house.

The third thing is about joining up. At a time when we all have really limited resources, we need to be smarter and wiser about how we use them. For example, we are working actively to take a co-ordinating role around no smoking day activity and the intended mass-media stop smoking campaign that the Government is planning for next year, to see how we can maximise the impact of such initiatives.

Alison Douglas

The point at the top of my list would cost nothing: it is about having marketing restrictions, particularly to protect children and young people, and looking at availability and how the licensing system supports and manages the widespread availability of alcohol in Scotland. Both those things would be perfectly deliverable without any spend at all.

Secondly, it looks as though funding for ADPs will be increased again and that is extremely welcome. However, there should be a clearer message about the expectations on them around preventative activity: the emphasis is too strongly on treatment.

Thirdly, like Sheila Duffy, I feel that there is a real gap regarding public communication. We know that 80 per cent of people are unaware of the low-risk drinking guidelines and that 90 per cent are unaware of the link between alcohol and cancer. We need to give people the information to make better choices.

Finally, we should look at mechanisms for ensuring that the health-harming industries that are driving such problems contribute to the cost of preventing and treating them.

The Convener

I thank everyone very much for their evidence this morning. As agreed previously, we will now go into private session.

12:24 Meeting continued in private until 12:57.