Health, Social Care and Sport Committee

Meeting date: Tuesday, October 3, 2023

Official Report 668KB pdf

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Pre-budget Scrutiny 2024-25

Our third item is a further evidence session as part of the committee’s pre-budget scrutiny for 2024-25. I welcome our witnesses, who are from the Scottish Government: Richard McCallum is the director of health finance and governance; Stephen Lea-Ross is the deputy director of health workforce planning and development; and Niamh O’Connor is the deputy director of the directorate of population health. We move straight to questions, starting with Evelyn Tweed.

Good morning. My questions are probably for Richard McCallum, but if anybody else wants to come in, please do. Are the financial pressures evenly spread? Might areas that are geographically remote or more deprived experience those issues more acutely? If so, how can that be mitigated?

Thank you for the invitation to speak this morning; we appreciate the chance to come along. The evidence that the committee has heard and some of the written submissions that have come in from other areas have been really useful in informing our budget considerations as we work forward. We will also get the committee’s report in due course, which is much appreciated. On Evelyn Tweed’s specific question about rurality factors impacting on the cost of services, that has come through in evidence sessions with the likes of NHS Borders.

I will highlight three things. First, there are financial pressures across the whole system. Whether you are in an urban or a rural health board area or in a more remote rural area, those pressures are felt across the system. Increases in inflation, for example, affect all boards. That point should be noted.

Secondly, you are right to say that there are particular challenges for remote and rural boards. There have been challenges around recruitment and retention, in particular, which can drive additional costs.

Thirdly, on what we are doing about that, I will make a couple of specific points. We have talked before at the committee about the NHS Scotland resource allocation committee formula, which is the key and main driver of funding for health boards in Scotland. As well as taking into account factors such as age and deprivation, the NRAC formula takes into account remoteness and rurality; it also takes into account factors that might drive increased costs.

When we allocate to health boards, we actively take account of the NRAC formula, but we also try to take specific actions and make specific investments on top of that. In primary care, for example, we are currently doing remote and rural healthcare work through NES—£3 million will be invested over the course of the next year to support that work, which will help to promote and support retention of services in remote and rural areas.

How are short-term and long-term needs being balanced? We heard a lot about both in evidence, especially in relation to preventative spend.

I will perhaps bring in Niamh O’Connor in a second to talk about some specific examples. The answer is that we have to do both, and the two are not separate. We know that we currently have some acute and specific needs as a result of the backlog of people who are waiting for services, and it is right and important that, as we come to the budget considerations, there is appropriate investment to support our health boards as they tackle those backlogs.

Equally, however, we know that, as you said, the longer-term reality is that we need to get upstream and ensure that we close off at the source some of the pressures that we currently see in our acute hospitals. Work is being done on multidisciplinary teams in a number of boards—we have seen a big increase in that—and we are looking to drive more support and care for people in the community. We are also doing a whole lot more with regard to wider investment—for example, on minimum unit pricing or other things in the alcohol space that are about trying to support very early prevention. Niamh O’Connor can tell you about some more specific actions.

Evelyn Tweed is absolutely right. Written submissions to the committee from Public Health Scotland, health and social care partnerships and the Institute for Public Policy Research, as well as evidence in the previous committee session, referred to the Scottish burden of disease. If we look at demographics alone, looking ahead to 2043, we see that there is a forecast 21 per cent increase in the disease burden.

The important point to note from that work is that that is the figure without any impact as a result of prevention or innovation—it looks only at demographics. Prevention and innovation often go together, and without those aspects being embedded at the heart of the long-term reform efforts in both population health and the health and care system, we will struggle to make the progress that is needed.

One of the vehicles is the care and wellbeing approach and, as Audit Scotland mentioned in its submission, we need to be clear about what we mean by prevention and preventative spend. The word “prevention” is often used and can mean different things in different parts of the system. We worked with Public Health Scotland around 12 months ago, and in January a publication was produced on clarity of definitions, and what we mean by the public health approach to prevention and the role of NHS Scotland in that respect. There is obviously a much wider role for other budgets, too.

That work clarifies three big components of what we mean by “prevention”. Primary prevention is about stopping health problems arising in the first place; vaccination is a classic example, and the budgets for that are key. Secondary prevention is about finding health problems early and intervening to stop them worsening, to produce better outcomes for people—screening is a good example of that. Finally, there is tertiary prevention, which is about managing established health problems as well as possible, ideally close to home, in order to minimise harms.

Ensuring that there is clarity around that definition system-wide has been really important. We did that work so that we would have national clarity for national cross-Government work on some of the wider determinants of health—the big building blocks. I know that, in its pre-budget scrutiny, the committee will be very much aware of, and alert to, the budgets outside the health and social care budget with regard to their impact on poverty, housing and the other things that we know drive health outcomes.

However, there are also local examples of prevention in action. In the primary space, a lot of work is being done around ensuring that NHS Scotland institutions become proper anchor institutions, with their huge footprint and ability to employ large numbers of people locally. There are also examples of anchors regarding the use of land and assets. Service redesign and service change are also taking place in the tertiary space. That is about shifting the balance of care.

I am happy to give a specific example if members would like to hear it. One example this year has been the community glaucoma service—I am happy to say a little about that.

Thank you.

I call Sandesh Gulhane.

Richard McCallum mentioned minimum unit pricing. Can you tell me exactly what benefit we have seen from that, please?

That work is still on-going and there will be further discussion about that in the coming months. At the end of June, Public Health Scotland published a report that highlighted that minimum unit pricing in its current form had reduced alcohol sales by 3 per cent. It also said that deaths caused directly by alcohol had reduced by 13.4 per cent and that hospital admissions had decreased by 4.1 per cent. Work and studies on that are on-going. Public Health Scotland cannot be specific, but the estimates that it has put in the report suggest that that is a direct impact of the minimum unit pricing that has been in place.

10:45  

Thank you for that. I am a bit confused, because what you have just quoted for hospitalisations is not a significant figure—it is an insignificant number, so that cannot be right. You talked about the reduction in deaths, but that, too, is not an accurate figure, is it? Actually, it is a potential reduction in an increase in rate compared to England. It has also been shown that dependent drinkers are continuing to drink. Could you explain how you have got to that figure and said that on the record?

Okay. I will bring in Niamh O’Connor, who worked closely with Public Health Scotland, which produced the report that I was quoting from.

Thank you very much, Dr Gulhane. I am aware that you have already put into the public domain your concerns about the evaluation that Richard McCallum just mentioned. As with all studies based on a robust evidence base or surveys—I am thinking of things such as gross domestic product or inflation figures—although the figures are estimates, there is real transparency around the robustness of the way in which those estimates have been derived. The Public Health Scotland evaluation of MUP had a really robust governance process, the details of which are in the public domain. There is expert opinion from people such as Professor Sir Michael Marmot and Professor Peter Rice, who wrote a letter that was published in The Lancet recently, in which they expressed confidence in the robustness of the approach and the methodology.

I know that the member has made very important points about clarity of communication around when things are estimates from studies, and the need to make sure that those are transferred into all products that try to explain the results of in-depth evaluations. There are very valid points around the use of, for example, the word “estimate”, and ensuring that that nuance is clear in products such as very brief evaluation findings or news releases. That is a very important point.

To go back to the UK Statistics Authority, its fundamental point was that the findings in that final PHS report had been communicated clearly and impartially. There is confidence in the robustness of that evaluation.

I have a quick supplementary question. Since minimum unit pricing was introduced, we have also had a pandemic. We have heard that, during the pandemic and during lockdown, there were changes in people’s consumption of alcohol. Some folk who drank a lot drank even more, and some folk who drank less drank even less. What are your thoughts on how the pandemic has affected alcohol consumption? Has that skewed any of the minimum unit pricing information that has been brought forward?

I am happy to come in on that. As the impact of the pandemic is better understood by global experts on alcohol consumption, there is a growing consensus that it had an impact on population-level drinking behaviours, especially among the harmful and hazardous category of drinkers, where there was increased consumption. We see noticeable double-digit increases in alcohol mortality in places such as the United States and Canada, and in other parts of the UK.

There is a growing global consensus that that increase is related to the pandemic, so the importance of the evaluation that we have just spoken about is that the findings on deaths averted are made in a controlled scenario that is based on what would have happened if MUP had not been in place. The findings of the evaluation were on population-level drinking behaviours, given the global pattern of the impact of the pandemic. Without MUP, it is plausible that the mortality rate in Scotland would have been much worse.

I did not respond to Sandesh Gulhane’s point about dependent drinkers, and I would like to make an important point about that. If Emma Harper is happy, I will cover that briefly now.

I am happy for you to do that.

It is very important to say that dependent drinkers are a small subset. Estimates vary, but potentially around 1 per cent of the population is at the extreme end of the spectrum, which means that they are harmful and hazardous drinkers who have clinical addiction needs that need clinical support.

I know that a number of committee members were part of the cross-party work with the Non-Communicable Disease Alliance on its recently published report, but it is a critical point that packages of measures are always necessary for complex social outcomes, because there is never a magic bullet, and that is the case for alcohol harm. Prevention is in the primary, secondary and tertiary areas—it is a kind of spectrum—so there are a range of measures around alcohol interventions, UK clinical guidance being updated and the investment going through alcohol and drug partnerships to support improvements in treatment for those suffering from alcohol dependency and addiction. That is a very important point, and the committee has made it well.

We now have a minister who has a combined portfolio that includes drugs and alcohol, and minimum unit pricing is not the only action that is being taken as a public health approach. You mentioned the Non-Communicable Disease Alliance. I took part in creating its report regarding NCDs.

My first question is a nuts-and-bolts one. Richard McCallum, how is the allocation of social care budget agreed within the overall health and social care budget?

We have conversations about that with the health sector and local government. We also have conversations with COSLA, which will be involved in the discussions that we will have during the coming weeks and months, as we move closer to the budget period. We will do that in conjunction with wider Scottish Government colleagues and, as I said, with external stakeholders—COSLA, in particular.

The key things that we will consider are the commitments that have been made and shaped in the policy prospectus and the programme for government. As committee members will be aware, one of the key commitments is to increase pay in adult commissioned services in social care to £12 per hour. We will take that into account.

The other factor that we will consider as part of the budget process is the overall allocation to health boards. Health boards allocate a further element to integration authorities, and integration authorities have overall budget responsibility across a range of health and social care services. Therefore, some of the consideration will be about the allocation of funds to IJBs, ultimately.

Okay. So, different stakeholders will pull in the data.

My second question relates to a previous committee session in which Philip Whyte, of the Institute for Public Policy Research, said:

“When it comes to staff, funding, resources and everything else, the balance of where we deliver care is still very much stuck in the secondary first model, rather than starting to look at what we can do to bolster the role of primary care.”—[Official Report, Health, Social Care and Sport Committee, 19 September 2023; c 3]

Is that a fair assessment, in your opinion? Has primary care been given the funding that it needs?

This point has probably been considered, including by this committee, for some time. We talked about the shift in the balance of spend from secondary acute care to community primary care and Scottish Government ministers’ commitment to shift that beyond 50 per cent over the current parliamentary session. We are just short of that, at around 49.2 per cent. Making that shift happen will be a key consideration in this budget and future budgets. So, at a strategic level, there is a key focus on moving spend.

There is a key commitment from ministers on that increase in primary care funding. Let us take the primary care improvement fund as an example. It has grown from £155 million a couple of years ago to £170 million a year ago and £190 million in the current financial year. A key consideration for us, because it is a fair challenge of out-patient primary care, is the need for that to increase further.

Good evidence is coming through on our work on multidisciplinary teams and community link workers, which is having a real impact. That is certainly part of the budget consideration, and some of the evidence that you have already received will be a big part of our considerations. Does either of my colleagues want to say any more on that point?

I am happy to come in with a specific example if the member would find that useful. We sometimes talk about shifting the balance of care in an abstract way, but I mentioned the community glaucoma service in the example of tertiary prevention and managing a condition as well as possible, and ideally close to home. That service has now been rolled out after a good number of years of work with community optometry, the ophthalmology profession and patients who receive the service. NHS Greater Glasgow and Clyde first sent letters out to patients. The service discharges clinically appropriate patients with glaucoma from the hospitalised service to management in the community. That is care closer to home. It is a concrete example of shifting the balance of care with appropriate work with our national boards, including NES, on the workforce developments that are required.

At its full roll-out, the service should be able to see up to 20,000 patients. NHS Lanarkshire is next to roll out, in November. We know that ophthalmology is often one of the busiest out-patient specialties. Philip Whyte, whom Tess White mentioned, referred in his evidence to specific examples of shifting the balance of care.

That all sounds good, but, last year, the Scottish Government cut £65 million from the primary care budget, which is a huge amount of money. How is primary care meant to cope with increasing demands when services are being cut like that?

I will say a couple of things on that. I think that you refer to the emergency budget revision that happened in November last year. That budget decision was taken in the context of a very challenging financial settlement across the Scottish Government, and all portfolios faced a financial challenge. That was a non-recurring production; it has not continued indefinitely. Although that pressure was recognised as part of the 2022-23 financial position, that £65 million revision will not recur.

As we have built up additional funding in primary care over a number of years, some of the money that has been allocated is in IJB reserves. There was an expectation that, rather than allocate additional funding to support things such as the primary care improvement fund, the integration authorities would use their reserves in the first instance, before additional funding was allocated.

That was the decision on the £65 million, which, as I have said, has not rolled forward into the current financial year. As you said, we know that primary care is incredibly important as we move forward, so we will consider that as part of the 2024-25 budget.

11:00  

Many submissions to the committee have highlighted the difficulty of engaging in forward planning and prevention while relying on single-year funding settlements that may be linked to evidence of performance in the short term. How is the Government working with health boards to support them to engage in long-term financial planning? How likely is it that we can move to a system of multiyear budgeting, given that many of the Scottish Government’s budgetary decisions rely on those of the UK Government?

That is a fair challenge, and I know that a number of boards and others have raised that issue with the committee.

There are two fundamental points in relation to that, one of which Ms Mackay picked up on. First, we are in a cycle of largely single-year budgets. Ultimately, money is allocated to us, as a Government, on a Barnett formula basis by the UK Government and it is quite difficult to plan ahead when there is uncertainty beyond the current year. That is not to say that we do not work closely with the Treasury and the Department of Health and Social Care at the UK Government level to understand expectations and plans. However, in a formal sense, even the budget this year will come after the autumn statement at Westminster. We work in that environment. Even over the past couple of years, with some of the general uncertainties that we have seen around Covid money, pay and other things, planning has been quite difficult, but we do it.

Secondly, multiyear budgeting would absolutely help, but we have tried to give health boards and integration authorities—we work very closely with health boards and integration authorities on this—some planning assumptions for future years. We have already mentioned the drugs budget, and there was a commitment to a £250 million investment over the lifetime of the Parliament. Boards, IJBs and other partners should be working on that basis. There is no expectation that we will stray from that; if anything, we would consider putting more investment into that. We have done that across a number of areas. We have mentioned mental health and primary care, as well as some of the planned care investment.

There is that challenge, but we try to give health boards and integration authorities as many planning parameters as possible in that context.

That is great. Thank you.

Data is a bugbear of mine—particularly how it informs budgets and outcomes. How can data collection be improved to ensure that it is not only sufficient to measure performance but is linked to long-term outcomes and therefore informs budgets and other things going forward?

Niamh O’Connor might want to come in on some of the specifics.

I hope that, at a strategic level, there is evidence and information that supports all our budget decisions. I will take something as specific as some of the planned care investment that has been made over the past couple of years, as that is considered as part of this budget. We will want to be absolutely clear about what we expect boards to deliver and about the improvements and outputs, in line with the trajectories that the cabinet secretary set out in the programme for government and the mandate letter. Maybe they are more outputs than outcomes, but we would want to be absolutely clear about that.

Niamh O’Connor mentioned the example of the multidisciplinary teams. We are starting to build up some strong evidence about the difference that those teams are making across primary care and mental health, as well as in other areas. You are absolutely right: as we work through this—again, it is something that we will be doing in conjunction with stakeholders—it is absolutely key that we draw on that data and that we base our budget investment decisions on where we are seeing real impact and change.

Given that she works closely with Public Health Scotland, Niamh O’Connor might want to say something about its input into some of this.

I am happy to say something briefly, if the member is content for me to do so.

I know that the committee has been concerned about the multiplicity of outcomes, frameworks and other ways of understanding change. What is important in that respect is, I guess, to understand which data to go to for what purpose. Where we need to, say, track investment or activity—that is, inputs into the system—there will be things such as previous local delivery plan standards and so on. I think that the committee member was asking about outcomes, so the question really is, how do we know that we are making a difference with regard to the outcomes that we are seeking?

As the public body that is the expert on prevention as well as the expert on data and analysis, Public Health Scotland is carrying out work that, I should point out, does not seek to duplicate something like the national performance framework but instead seeks to clarify what we know drives health inequalities and the measures around those—for example, the early years, good work, good income and our outcome indicators around all of that. It is learning from the experience from Covid, too, and it is working with the Improvement Service on dashboards that will be useful locally in community planning when people organise efforts to address, on a local basis, health inequalities and health outcomes. That care and wellbeing dashboard, as it is called, was launched in June, and it is what we are using to track progress on the overall outcomes. Evaluation is the key link between the data on our interventions and our activities, the data on the outcomes and what is plausibly driving both—either whatever lies within the gift of the Scottish Government as a whole or, indeed, wider factors, of which there have been a number in the past decade.

I call Carol Mochan.

Thank you very much, convener.

My question probably links with what has just been said, but I am interested in finding out whether and how the Scottish Government tracks spending by each NHS board on its current policy priorities.

I will bring in Niamh O’Connor in a second to give you a couple of specifics. In a general sense, we work through our policy teams within Government. On specific commitments on, say, mental health, alcohol or drugs, we work very closely with our boards and IJBs to ensure that information is returned to us to provide clarity, not just on spend but, crucially—as you have said—on the investment that is being made and whether early outcomes are being seen.

At a data level—again, this speaks to the work that Public Health Scotland does—we have a cost book that essentially annually translates the budget and what the Scottish Government has invested, and tracks how that investment has been spent by our health boards. It starts to give us a good picture of things. There is a time lag—we do not get the information until a few months after the year end—but it still gives us a good sense of whether, in the areas on which we are focusing our investment, which we have already mentioned, and where we are looking to see more investment in the community, things are being borne out in reality. The past two to three years have been difficult and things have probably been skewed somewhat because of the challenge of the pandemic. Nevertheless, we are building evidence and data back up in the cost book, and that is certainly something that we will be looking to build on as we move forward.

Do you want to add anything, Niamh?

I can briefly add something.

Richard McCallum has just talked about tracking investment. The member asked about outcomes by board against, for example, the commitments in the prospectus. The dashboard that Public Health Scotland has launched, and which I have just mentioned, contains all the data to provide evidence on what we know influences health and health outcomes. That data is available by health board area and can therefore be broken down. The dashboard is still at an early stage and information is still being added to it; however, where data is available by local authority area, work is taking place to make that breakdown available, too. That is just one element of how outcomes are being tracked by geography.

Secondly, I want to amplify one of Richard McCallum’s points. Investment in prevention is critical—not least investment outwith the health and social care budget, such as the very big investments in the Scottish child payment. However, when we look back over the past 20 years at some of the things that have made the biggest difference in public health—in preventing ill health and in making improvements in mortality in relation to cardiovascular disease, for example—we see that legislation has had an important role, too. For example, there have been non-fiscal interventions such as the smoking ban in 2006 and a package of other measures, over time. That issue was mentioned in the written submission from PHS.

I hope that that is helpful.

It is. To come back on that a little, I note that sometimes—particularly with big spends—it can be hard to see where money has been moved about. Could we record anything differently, or better, to enable scrutiny and ensure transparency on where money actually goes once it is in the system?

In the budget, for example, the committee will rightly often see that broken down into large spend areas—planned care or others—and then broken down by health board, but you do not necessarily get the detail or data on how it is subsequently spent. I mentioned the cost book, which is critical to seeing whether the budget that we have set translates through into spending that is, ultimately, undertaken by health boards and others.

We want to do more on that issue—we are doing more on it—as we move forward, on some of the key investment areas that we have talked about. We would welcome the opportunity to come back to the committee on the issue and to give you that data, because it is important and helpful for you to see it, as well.

There have been advances in relation to mental health budgets, which we can see more clearly. As you said, there is scope to look at other areas, which would be helpful for members and for the committee as a whole. Thank you.

My question is similar to Carol Mochan’s. Do you feel that we have enough transparency in the way that taxpayers’ money is spent, and do we have the ability to really track it so that we know where all the money is going?

The investment that we put in the health and social care system is no secret. If you, as a committee, feel that there is information that you are not seeing, or you would like more information, I would be pleased to give you it. It is absolutely crucial that you can see it, and that you can hold us to account on it.

In answer to the question, I say yes—I think that we have good information in the cost data that we have, but we can always improve it. I see the information at two levels, in particular—health board and IJB levels. It is absolutely important that local communities have a clear sense of where boards and integration authorities are investing their spend. We get annual reports from integration authorities and health boards, which set that out and give that detail at least annually, which gives a sense of how the money that has been allocated to those areas has been used. That is critically important.

Similarly, I have mentioned the cost book and the data on overall spend at national level. The Government has asked integration authorities in particular to detail how they have used particular funding streams. Ms Mochan mentioned mental health, but there are other areas for which we have that information and are pulling through the data. However, if we can do more to give the committee that information or make it public, we would be happy to do that, because it is absolutely important that we are transparent in tracking spend.

11:15  

Thank you. In previous evidence sessions, we have been told that it is very difficult to track how money is being spent and where it is going. I asked the question because it is important that we are able to define transparently and clearly where taxpayers’ money is going. Given your answer, do you feel that you can track all the money that is being spent and exactly where it is going?

It is a huge budget, obviously, and investment is made in many areas and priorities across health and social care. However, as I said, at a local level, health boards and IJBs can provide a lot of that data and information; indeed, they are already doing that in their annual reports. We follow up and track all investment.

I will go back to Ms Mackay’s earlier question. One of the key things—especially given the financial constraints that we have and are likely to see over the next few years—is that we must be confident that our investments are making the differences that we want them to make.

There can be challenges, including in getting that information back in a timely way. To go back to your earlier question, I note that we want to ensure that all the information is accurate. However, there is a clear way that we can and will track that spend. We absolutely can track spend on the specific policy areas that we have picked up on today. As I said, I am more than happy to provide as much of that information to the committee as you would find helpful.

Thank you.

I declare my interest as a practising NHS GP.

Many of my questions have been answered or touched on. We have heard about the care and wellbeing dashboard. We hear a lot that short-term targets can drive decision making, but I am interested in longer-term objectives. What can we do to encourage setting of budgets with that in mind?

Niamh O’Connor might want to say a bit more about the care and wellbeing portfolio and the work that is being taken forward there. The starting point is that the programme for government and the mandate letter that was issued a month or so ago will be the primary consideration and drivers in our budget considerations. The cabinet secretary has been absolutely clear that it is about recovery and reform and holding those two things together.

There are certain immediate pressures in secondary care, and there are immediate pressures in planned and unscheduled care. If additional investment in those can be effective, we should look at the options to take that forward. Investment in things such as the hospital at home service has absolutely supported our doing that.

However, the point is that I see that not only as a short-term investment. We hope that hospital at home will have an impact this winter and will help with the unscheduled care challenges that we will undoubtedly face, but it is also a long-term solution. The outcomes from care and treatment at home are good, and better, for the people who receive that service. Therefore, we recognise that there is a balance to be struck, in that there is short-term investment that we also see playing out with the longer term in mind.

The reform element is absolutely key. We are using the care and wellbeing portfolio as an example, which the committee has received evidence on before; I think that it was discussed at the PFG session with the cabinet secretary. It will be a key mechanism for driving forward some of the reform that you mention.

Niamh—do you want to pick up on anything specific?

Could I ask you, Niamh, to touch on keeping people’s experiences at the centre, as well?

Yes, absolutely.

The point of the care and wellbeing portfolio is for it to be the long-term reform place for population health in relation to the big risk behaviours that we have spoken about reducing, and for service and whole-system reform, including in wider government. The £3 billion investment in tackling poverty, for example, is absolutely critical in relation to benefits and the building blocks of health.

The long-term point of the portfolio is to bring all the reforms together in one place. Besides the service reform and population-health measures that we have spoken about, there is work being done on areas such as innovation, digital and analysis—on building those capabilities in Scotland so that we are best able to deal with long-term challenges.

One of the other big cross-cutting areas is co-design, service design and engagement. The committee might already have heard about some of the summer design events on national care service development. Part of that has been the establishment of a lived-experience expert panel. When we speak to people, we know that they do not live policy-siloed lives. If they are speaking about their experience of social care, it will often extend to their experiences of local healthcare services. That information is all being gathered together and used to inform the thinking on long-term reform and developing the building block of constant public engagement that we need in order to reform services for the long term.

That leads on to my next question. How can the interdependencies between various spending areas be better taken into account when making budget systems and looking at performance frameworks?

I will take that first.

I will make a couple of points. Niamh O’Connor touched on how, when we talk about some aspects of primary prevention, a lot of the spend is well outside the health and social care portfolio. As we move forward with this and subsequent budgets, having a real and clear connection across areas will be key—across education, justice, housing and local government, for example. It is a whole system and a whole package, so there is consideration in a number of areas.

We are doing a lot within the portfolio but, no doubt, there is more that we could do. We have talked about primary care as being the place where most interactions in our health and social care system—certainly in our healthcare system—happen. Work that has been done on multidisciplinary teams and community link workers, which we have touched on, is making a real impact in relation to investment in mental health and other conditions. We are starting to build that up. We are not seeing the siloed approach within our portfolio; we are trying to make sure that our investment is coming together through the portfolio, as Niamh mentioned, so that we are making the best funding decisions and making sure that it reaches people in the best way possible.

I can add a specific example, if Stephanie Callaghan would find that useful.

Certainly.

We spoke a little about benefits and things such as the Scottish child payment and the impact on the building block of addressing poverty. Obviously, benefits’ impact on preventing ill health is felt only if individuals claim, or can access, the benefits that they are entitled to, so a lot of work is being done in relation to interdependencies between NHS services and wider services, in order to ensure income maximisation.

A recent example is NHS Lothian’s having established income maximisation services across every hospital in the NHS Lothian estate. The board is starting to gather management information on that and, in the nine months to June this year, more than 700 patients who were often at vulnerable points in their lives, when they were accessing healthcare, got the benefit of the income maximisation service. That is a whole-system change that has been funded partly by NHS Lothian Charity, and managed and overseen by the public health experts in NHS Lothian.

From the management information, we can see that the confirmed financial gain was around £400,000 just in that nine-month period. The solution is, therefore, to have a combination of national interdependencies and local action. As I said, the impact on preventing ill health is experienced only where households have the benefit of national policy changes and measures such as the Scottish child payment.

That is a great example. Thank you very much.

I thank the witnesses for their contributions so far. I want to turn to health and social care outcomes. Many written submissions to the committee have noted that the short-term nature of national targets is impacting on clinical priorities for investment. Decisions are often made to satisfy expectations in the short term, as opposed to the long-term impact of patient investment being measured. What are the panel’s views on alternative measures for monitoring performance that would allow for longer-term planning and more rational decision making on investments?

That is a consideration for ministers, in the first instance. As for investment decisions, or the choices that we are making, I do not see this as an either/or situation. The more immediate standards and improvements that we want to see are referenced in, for example, the programme for government. That is absolutely right, and it is the expectation of the population, so we ensure that those are factored into our investment decisions.

However, it is key that we have an eye on the longer term and do not make short-term financial decisions just to meet immediate pressures. The medication-assisted treatment standards that form part of the national drugs mission are an important example of that combination approach of wanting improvement in the short term and seeing the need to address the longer-term challenges. I think that we can build up more activity in that area.

Public Health Scotland’s work on examining data over a longer period will help to inform our longer-term targets. On our budget choices, it is about finding the right balance between immediate service needs and the longer-term focus. [Interruption.]

Have you a further question, Mr Sweeney?

Yes. Sorry about the delay; I was waiting for my microphone to be unmuted.

That point is fairly made. However, I recently met GPs in Glasgow who said that they are so focused on dealing with immediate clinical requirements, which are overwhelming, that it is just not feasible for them to have any head space or time to consider continuous or process improvement with their teams in practice. There is not the capacity or the space to undertake such activity.

That really goes to the core of the tension between short-term firefighting and longer-term continuous improvement. The biggest commodity in the NHS is, of course, time. How can we move the NHS, as what we might call a learning organisation, away from such firefighting and being in crisis mode into creating a space for continuous improvement and for workstreams that can help to drive activity? For example, is there an account management service, or do you bring in specialisms from other industries? For instance, many economists say that we should look to the aerospace industry for good examples on how to drive productivity.

The NHS is the single largest employer in Scotland so its approach will have an impact on our national performance. How can we move to getting the everyday economy in areas such as the NHS mobilised in the same way? How can we bring a culture of productivity improvement into the service? Have you ideas for how that could be achieved?

11:30  

That is a really fair challenge. As the committee will know, the reality is that, after two or three years during which a lot of our services were, for understandable reasons, scaled back or curtailed, we have a backlog and there is real challenge in the media, so that investment is really important.

I will bring in Stephen Lea-Ross in a second to talk about some of our work with system leaders to look at the question about developing our staff, leadership and productivity.

The primary care point that you raised, Mr Sweeney, is a challenge. The investment that has been made in multidisciplinary teams—the number of staff working in MDTs has grown to more than 4,500—will, I think, have an impact. It is something that we are looking at for the future.

In terms of the pressure that GPs are facing, and in relation to the example that you highlighted, we hope that MDTs will have an impact on that and assist GPs as we move forward. Clearly, phase 2 of the contract will be a key part of it. I know that you have evidence-taking sessions with primary care colleagues coming up. I am sure that they would be happy to expand on some of those points.

Your point about productivity is right in that that is partly about the money that we invest. However, it is also about making sure that we get the best value for the money that we invest and ensuring that our system is as productive as possible, while recognising that, in many instances, our staff have been through some significant challenges over the past couple of years. It is about holding that balance in line.

Steve, do you want to talk about some of the work that we have done with our staff to support them?

Yes, I am happy to do so. I will make a couple of broad strategic points, then perhaps give a couple of examples in response to the overarching question on productivity.

One of the things that we have tried to do through framing the new national health and social care workforce strategy, which we published in March 2022, is to draw out the relationship between recruitment, staff development and training and the infrastructure, technology and tools that staff use to do their jobs. Part of what we are now trying to embed through the workforce strategy implementation programme is the drawing out of the links in that relationship, particularly between where staff are working and how staff are working in terms of their relationship between one team and another and their access to tools and equipment.

In addition, to pick up Richard McCallum’s point about encouraging whole-system recovery after the acute phase of the pandemic, we have invested quite significantly—this is set out in the strategy—in physical and psychological supports for staff, not only to encourage attendance but to allow them to reset and rebalance themselves following the pandemic.

Richard McCallum has already picked up the point about the growth in staffing in MDTs, and we can see through the national monitoring and evaluation strategy for primary care and through some locality-based evidence where that is already having an impact on releasing GP time by embedding additional physiotherapy support, community link worker support and pharmacotherapy support. That is also demonstrating a more efficient use of resources with better patient outcomes, particularly in relation to pharmacotherapy examples.

We have looked at our approach to planned care recovery, staffing and productivity. In partnership with the Centre for Sustainable Delivery, we have looked at a range of interventions that try to increase the productive opportunity in those centres without meaning that—I have to stress this—staff have to work more hours or do more work. It is about aligning the whole of the system end to end and looking at the productive capacity across the whole of our estate in NHS Scotland.

Through the national elective co-ordination unit, for instance, we have managed to use what was previously a little fallow capacity in certain theatres throughout the country, delivering about 3,500 additional elective procedures so far this year. We have also been looking at the structuring of teams and workforce diversification in that area, in particular to improve productivity progressively without increasing the direct burden on staff in front-line services.

Thank you for that. Do you feel that lean improvement—continuous improvement—is very much driven from the ground up, and that it is often the innovators on the front line who have the best insights on what we need to do to improve productivity and efficiency?

With that in mind, do you feel that we could do more on continuing professional development, even looking across to different Scottish Government agencies, such as Scottish Enterprise and the Scottish manufacturing advisory service, to teach tools and techniques that could allow more practitioners in the national health service to identify opportunities where there is waste and where efficiencies could be achieved? In that way, we could start to develop those ideas organically and move them forward.

I will come in on that first—Stephen Lea-Ross might want to add a couple of things.

I will give an example. You are right—it is often our staff who have good ideas for how we can improve our work. A specific example is climate. The national green theatres work that we are taking forward has been clinician led. Clinicians, in particular in NHS Highland, have come together not only to identify monetary and productive efficiencies but to do work on, for example, anaesthetic gases and waste separation. That has not been the result of an edict from on high, albeit that we are very focused on the on-going work on sustainability—the theatres project was led by teams in the system. You are right to highlight that how we harness that will be key as we move forward, because the best innovative ideas often come from the front line.

That said, there is also wider harnessing. You mentioned Scottish Enterprise, for example. Across our innovation landscape, we are doing a lot of work with colleagues in Scottish Enterprise and in the Scottish Government economy directorate on the research projects that we have under way. We have seen real benefits coming through from that—for example, from the work on closed-loop systems for diabetes and on theatre scheduling. A lot of innovative work can be done. We need to ensure that we invest in that and that people have the time to focus on it; however, given the challenges that we face, it is right that we drive that forward.

I do not know whether Stephen Lea-Ross wants to add anything.

I will give a couple of other practical examples. Again, through our work on elective recovery, we took a bottom-up approach to developing staffing models directly with theatre teams across the national treatment centres that have opened or are in the process of opening this year, in particular in NHS Highland and NHS Fife, and with NHS Golden Jubilee National Hospital.

We invited clinical staff themselves to challenge assumptions around the staffing model and the staffing mix; to engage with the challenges that exist in the wider economy with regard to attracting particular groups of staff; and to look at what alternative staffing solutions there might be. That led to positive change on rethinking the mix, in particular in the centre in Inverness, and rebalancing the number of registrants with support staff. That work begins to feed into a pipeline when it is tied together with the work that is being done around anchors and future development.

That said, there will have to be an increased focus on the productive capacity and opportunity that might come through future technological innovation with regard to both how our staff work and the tools that they have to do their jobs.

Again, that is something that we have framed in outline in the national workforce strategy. There is further work to do on scoping where we might be in the next five to 10 years. Quite a lot is being done in the context of the innovation design authority on how artificial intelligence can support imaging staff. AI can support the administration of staffing and how staff are rostered and used throughout the system. Some systems innovation is being driven by the wider landscape that we are looking to embed as part of the overall approach to balancing staffing, productivity and service need.

We have limited time left, but we have quite a few questions still to ask. I ask everyone to be brief and I will have to practise what I preach. I declare an interest as a registered mental health nurse.

I am keen to move on to the topic of workforce and pay. How can the twin pressures of increased pay and demands for additional staff in the NHS and social care be balanced within the limited resources of the Scottish Government budget and its limited borrowing powers? That might be one for Stephen Lea-Ross.

At the outset this year, we took a clear overall strategic approach in reaching the pay settlements, both for agenda for change staff and for doctors and dentists. We sought to reach a fair, proportionate and reasonable settlement in the context of the wider economic circumstances and to proactively minimise the disruption that would have occurred had there been a breakdown in industrial relations.

There are two points about the balance. I will try to be as brief as possible. Looking ahead, we have to look at the totality of terms and conditions. Although we have made the investments over the course of the year and pay will continue to be determined through that tripartite process directly with unions, we are looking at the balance of investment in pay going forward with progressive terms and conditions reform. When we look at international benchmarks for careers in health and social care, it is the total package that makes them attractive. In the context of present-day shortages in health and social care personnel, retention is as important—if not more important, given the acute pressures—than investment in recruitment. That is not to say that we should spend on one rather than the other, but we have to take those strategic decisions in view of the total economic context in which we are operating.

Thank you for your brevity in that complex answer.

I will be quick because a lot of information has been covered already. In our previous evidence session, the witnesses talked a lot about whole-system approaches to the budget. We know that we need to tackle poverty and health inequalities and the impact of housing on those—there are loads of umbrellas that are needed to support the improvement of the health of the people of Scotland. I am interested in public health and preventative approaches. I am interested in the ability to have a good healthy diet, for example. I am interested in the work of Henry Dimbleby and Chris van Tulleken, as well as Professor Pekka Puska’s work to improve diet to reduce cardiovascular disease. What work is being done to learn from other researchers who are not even in Scotland, to see how we can budget better for public health measures?

Niamh O’Connor will be able to give some of the specifics on that.

You are right—it all comes back to evidence-based budgeting. That is what we are seeking to do on a global as well as a granular scale. We talk about diet and obesity and the investment that we are putting into that. Key for us when the policy teams consider the issues and we make those investment decisions is what the international evidence shows us and how we can evaluate that as effectively as possible so that our investment really maximises our contribution.

I know that we are short of time, but Niamh might want to add something more specific.

11:45  

I will be brief. It is exactly as members of the committee said in relation to the NCD Alliance report; it is about the whole package of measures and learning from other systems. We need to think about the criticality of early years, the Heckman curve and return on investment; all that is part of the nutrition policy landscape, as are free vitamins for under-threes and breastfeeding mothers. The whole-system approach to diet and healthy weight has to start at the earliest opportunity, and it has to include the whole package of legislative and fiscal measures.

When the Minister for Public Health and Women’s Health was here for the programme for government evidence session recently, she signposted the next steps on trying to restrict promotions of foods that are high in fat, sugars and salt, which has a strong overlap with some of the Dimbleby concerns that you mentioned. There is active work on bringing that forward as soon as possible.

The Institute for Fiscal Studies has published an interesting report on short-term, medium-term and long-term planning. It focuses on the fact that the Scottish Government’s health budget depends on Barnett consequentials, so it is determined by the UK Government. If we do not know what is coming from the UK Government, does that pose challenges in determining what needs to be incorporated into preventative health planning or acute planning?

That loops back to Ms Mackay’s question. In general, we get the consequentials annually, albeit that we are making some assumptions about future years. Once the total Scottish Government budget comes, ministers can choose to use it how they wish, but, if we were to put even more into health, it would be at the expense of other portfolios that have equally pressing needs.

In the past year, funds in excess of consequentials have been put towards the health and social care budget, so it is a challenge that needs to be worked through. In that context, we are trying to ensure that we have a clear financial framework that we can use to make the decisions that will impact us over the next five to 10 years.

Paul Sweeney has a final brief supplementary question.

I am intrigued about practical realities. How do you pivot the healthcare system from current acute spend in hospitals towards preventative spend in communities? We spend more on acute hospitals than any other healthcare system in the developed world does. How do we shift the balance practically?

That links to a lot of what we have said. It is partly about building on the up-front investment that we have made in preventative areas, which will need to continue. I do not necessarily see it as an either/or situation. It is important that we continue to invest in our secondary care services and make sure that the funding is available when we need it. That will partly happen through deliberate budget choices, but not only through budget choices. Policy choices that do not necessarily come with huge financial costs will help to shift the narrative and the service delivery.

I thank witnesses for their attendance this morning, and for the evidence that they have given to the committee. At our next meeting on 24 October, we plan to take further evidence on the National Care Service (Scotland) Bill. That concludes the public part of our meeting.

11:49 Meeting continued in private until 12:26.