Contents
- Attendance
- Decision on Taking Business in Private
- Section 23 Report: “NHS in Scotland 2022”
Section 23 Report: “NHS in Scotland 2022”
The principal item on our agenda is an evidence session on the Audit Scotland section 23 report, “NHS in Scotland 2022”. In the interests of transparency, I refer members to my entry in the members’ register of interests, which includes membership of two trade unions that organise in the national health service.
I am especially pleased to welcome our three witnesses: Caroline Lamb, chief executive of NHS Scotland and the director-general of health and social care; Richard McCallum, director of health finance and governance in the Scottish Government; and John Burns, chief operating officer in NHS Scotland. You are all very welcome. We have quite a number of questions that we would like to put to you. Before we get to those, I ask Caroline Lamb to make a short opening statement.
Thank you, convener.
I welcome the report and the close engagement between Audit Scotland and my team, which is so important. The new First Minister has set out his priorities for this parliamentary session, which include a determined focus on the recovery, reform and improvement of NHS and social care services. Audit Scotland’s report clearly sets out the challenges that the NHS and social care face as a result of the pandemic, and notes that Covid and other respiratory viruses continue to impact on services. The report highlights our focus on recovery, which has included a successful vaccination drive and a significant reduction in two-year out-patient waits. Ministers have met the commitment to provide over £1 billion of additional funding for health and social care in 2023-24, which takes the total allocation to over £19 billion. It is for me to ensure that that funding is used effectively to drive the reforms that are needed and ensure that people receive the treatment that they need as quickly as possible.
The First Minister, the Cabinet Secretary for NHS Recovery, Health and Social Care and I understand the importance of reducing hospital occupancy to ease flow and improve capacity for urgent, unscheduled and planned care. We will do that through increasing capacity in primary, community and social care. NHS 24 and the Scottish Ambulance Service have successfully increased the number of people whom they help without needing to attend accident and emergency. The report also notes other work that we are doing to increase our capacity to care for people outside of hospital. About 97 per cent of discharges take place without any delay, but addressing the remaining 3 per cent that are delayed, and their impact on the whole system, is of critical importance. We have worked hard with partners in health and social care to understand the actions that improve discharge flow. We will continue to support systems to improve those actions over the coming months.
Central to our recovery is, of course, the £1 billion NHS recovery plan. That includes increasing activity through the establishment of national treatment centres, investment in mobile theatres and diagnostic facilities, and using the centre for sustainable delivery to maximise the impact of the resources that we already have. There are some indicators of success. Scotland’s A and Es have been the best performing in the UK for over seven years. An average of 591 operations were performed each day in February 2023, which is 15 per cent higher than in January 2023. Of course, we all want to go further and faster, but we need to acknowledge the progress that has been made, given the continuing shock that has resulted from the pandemic.
I finish by, once again, thanking our exceptional health and social care staff. My colleagues and I are happy to take your questions.
Thank you very much indeed.
Do you accept and agree with the findings and recommendations of the Auditor General for Scotland?
Yes, we accept the findings of the Auditor General. We will work with colleagues across health and social care systems to ensure that we take forward the recommendations in the report. We accept absolutely that the NHS is in challenging times, and we are all focused on trying to navigate a path through that.
Okay, thanks.
Do you accept the point made by the Auditor General, in paragraph 99 of the report, that
“The wording of the new targets is open to interpretation”?
There is a question mark over whether waiting time targets are properly useful and transparent for people. The report also notes, in paragraph 105, that the Office for Statistics Regulation has deliberated over the statistics produced by the Scottish Government on waiting times and concluded that they could be misleading because they are based on median waiting times. Do you accept that criticism?
We are absolutely determined to be transparent and open with the public, with Parliament and with Audit Scotland. Audit Scotland attends our regular assurance meetings. It is a very complex picture. Planned care, unfortunately, is impacted by the pressures on urgent and unscheduled care. We are working with NHS boards and through national modelling. John Burns will say a bit more later on about our work on national and local modelling, particularly for planned care.
On the specifics of the online waiting times platform, it was developed in collaboration with Public Health Scotland and NHS 24 with the intention of providing information about typical waits. You will appreciate that it is a very complex picture. The statistics are quality assured and collated by Public Health Scotland and we continue to improve that. Updates have already been made to provide more information and a link to the official statistics sites.
Okay, but we had an exchange of correspondence about a year ago and you wrote to me on 13 May 2022, saying:
“We are committed to being open and transparent about data on waiting times performance”.
However, several months later, an Audit Scotland report comes out and points out that not only have you been criticised by the Office for Statistics Regulation because your waiting time target information is not transparent, but you are being criticised in a similar vein by the Auditor General.
As I said, convener, we are committed to trying to provide transparent waiting time information, while recognising that it is a complex picture. We have worked with Public Health Scotland to provide that information. Public Health Scotland has accepted that criticism and is looking at ways to improve that information. We are committed to being able to provide that information in a transparent and open way.
When can we expect to see that?
I will need to contact Public Health Scotland to get further information on that and I commit to getting back to you about it.
Okay, thank you.
Another area identified in the Audit Scotland report is the delays to the roll-out of the national treatment centres, which we all understand are critical in regard to tackling waiting times and the backlog. They are critical not just in addressing the immediate pressures but in providing a longer-term route for getting people the treatment that they need. There has been a delay. Can you tell us where we are with the opening of the national treatment centres, some of which were meant to open last year and are still not open?
Yes, absolutely, convener. Again, colleagues will understand that, given the issues around building projects during the pandemic, it was perhaps inevitable that we would see some delays. However, the national treatment centres in NHS Fife and NHS Highland are now open. The national treatment centre in NHS Forth Valley and the extension to NHS Golden Jubilee are on track for the end of this year. The treatment centres in NHS Fife and NHS Highland are open and treating patients.
The rest of the programme is in different stages around the preparation and proper scrutiny, as you will appreciate, of business cases and we are working with NHS Scotland assure to ensure that we provide the best possible facilities. Clearly, there have been issues around cost inflation, but those business cases are working through the process. We are not waiting for more and more physical premises for national treatment centres to come on train; we are also very focused on what we can do and how we can increase productivity in our existing estate. John Burns will want to say more about that later. As I mentioned in my opening remarks, that has included providing mobile facilities to boards to help them to up their activity.
Earlier, you said that the NHS Forth Valley’s Larbert site treatment centre and the expanded one at NHS Golden Jubilee at Clydebank will be open by the end of the year. Can you give us a definite commitment that, by December 2023, those two centres will be open and receiving patients?
Yes, they are on track to be opened in December.
John Burns, are you confident about that?
Yes. We are working closely with the boards and are confident that, unless there are any unforeseen circumstances, those projects are on track to be opened by the end of the year.
Okay. If, for example, the NHS Golden Jubilee site is open by the end of the year, how does that compare with when you expected it to be open when the construction work was originally procured?
We will need to come back to you on that one. Clearly, there have been changes as we have gone through the pandemic. I commit to providing that information to the committee.
You accept, though, that there has been a delay.
Yes. Inevitably, there has been a delay, as we have seen on the site of most building projects during the pandemic.
As a committee, we are used to delays. Sometimes, they are not as inevitable as you perhaps suggest. What does the delay do to the cost of those projects? Will they come in on budget, or will they be over budget because of that delay?
Richard, do you want to come in on what our expectation is?
Yes. For projects that have already been built, we had an agreed budget in the outline business case. When they are then returned with the final, full business cases, we expect the budget to be in line with those full business cases. There is some risk to that because of the infrastructure inflation that we are seeing across all our infrastructure programmes at the moment. However, if there were to be any deviations from that final business case, we would expect to be informed by the project as it moves towards completion.
I am sorry to labour the point, but what is the budget, for example, for the Larbert site? What is the budget for the NHS Golden Jubilee site? Where do they now sit?
I will come back with the detail. I do not want to quote incorrect figures for those two sites. We will make sure that, for all the NTCs, you have that breakdown of the initial budget and where that spend is against those programmes.
Okay. A lot of this morning’s discussion will be about the financial pressures on the national health service. Caroline Lamb, you are the accountable officer responsible for £19 billion of public money, so it is quite important that we get an understanding that you are on top of the pressures that you face. I will turn to Craig Hoy, who has some questions to put to you.
Good morning, Ms Lamb. The Scottish Fiscal Commission’s fiscal sustainability report that came out last month raised serious concerns about future financial pressures on the NHS in Scotland. It identified that those pressures are due not only to an ageing population but to rises in chronic health conditions and the technological advances that are moving us forward. What are you and the NHS in Scotland doing to plan for those future financial pressures to ensure that Scotland’s NHS is financially sustainable?
Clearly, we are mindful of the pressures that result from the demographics and an ageing population. We look at the Scottish burden of disease information to determine the likely demand on health and, indeed, social care services. We also have our innovation design authority and accelerated adoption programme to look at innovations, which can often address some of the pressure. As I said in my opening remarks, investment in NHS Scotland is at an all-time high—it is sitting at £19 billion. We need to make sure that that money is spent in the best way possible, so we look at our projections to see what the additional burden of disease looks like.
09:15Key to that is looking at what we can do, not just in the Scottish Government’s health and social care portfolio but across the Government, to improve population health and address health inequalities, a lot of which are rooted in social inequalities. Tackling poverty, poor housing and educational attainment contributes to improving population health and therefore helps us to mitigate the increasing demand on healthcare services.
As I said in my introductory remarks, we are looking at how we can increase capacity in primary, community and social care, with a view to ensuring that people are in hospital—the most high-end part of our system—when they need to be there and that they can be treated elsewhere, and closer to home, when that is appropriate. A huge amount of work was done in the run-up to last winter, as will be the case in the run-up to next winter, in relation to how we can use NHS 24, and the SAS in particular, in the community to prevent people from being admitted to hospital.
The point about innovation is a really good one. Yes, expensive drugs and innovations are coming over the horizon, but, equally, innovation through the use of digital technologies presents us with the opportunity to deliver healthcare in a different way—one that is closer to people. There are lots of good examples, such as using colon endoscopy as part of our approach to diagnostics. We are rolling out digital dermatology, which saves people from having to travel to a hospital, and closed-loop systems for diabetes, which help people to manage their insulin levels in a way that prevents some of the burden of illness from developing. We are therefore looking at innovation from multiple directions.
The SFC estimates that projected spending on health in Scotland will rise from a third of all spend to 50 per cent within 50 years. Do you recognise that figure? What conversations are you having with ministers about the model of healthcare in Scotland, given that projected shift in spending?
A lot of that relates to what I have just said. It is about how we can reduce demand for and take away some of the pressure on services by improving population health. That is a cross-Government initiative. It is about what we can do to reduce social inequalities that feed into health inequalities, poor health and poor health outcomes for people. It is about reducing demand and thinking about what else we can do. Huge progress has been made in relation to some of our out-of-hospital pathways, which provide care to people in their home rather than in hospital. It is about doing more of that and about embracing and adopting innovation. I suspect that, over the next few years, we will see more potential from artificial intelligence and other areas. Our job is to focus on what we can do to ensure that we provide health and social care services in a way that meets the needs of the population but that is sustainable in the context of overall budgets.
That is a long-term sustainability issue. In relation to the shorter term, the leaked draft minutes of a meeting of NHS board chiefs in September last year identified a potential £1 billion black hole in the finances of the NHS in Scotland. The minutes of that meeting of NHS bosses stated that they had almost been given the green light to think the unthinkable about the foundations of the NHS in Scotland, with the wealthy potentially paying for their treatment in a two-tier NHS. Is that the kind of discussion that is taking place in NHS Scotland?
No, that is not the kind of discussion that is taking place in Scotland. I am on the record as having said that I did not give the green light to having discussions about challenging the very foundations of NHS Scotland. I meet regularly—at least monthly—with chief executives in NHS Scotland. We talk all the time about opportunities for cost improvement and for delivering services differently and in a better way. I do not want anything to be off the table in relation to how we can provide services differently and in a way that supports people in the way that they need to be supported, but that is not about challenging the foundations of NHS Scotland.
I accept that. However, the draft minutes of that meeting say that somebody gave the
“green light to present what boards feel reform may look like”.
Fundamentally, they say that
“areas which were previously not viable options are now possibilities”.
What are those viable options?
I just want to be clear about the genesis of those minutes and my understanding of the situation. I was not present at that meeting, and it was not a meeting of NHS chief executives. There might have been one chief executive there and some of the functional leads—the people who chair other groups—such as medical and nursing directors and directors of planning. I was not at the meeting, so I cannot describe the context in which that conversation took place. From my review of the minutes, it looks as though that was a little bit of blue-sky thinking and that they did not think that all the things that they were proposing were reasonable and would be taken forward by the Scottish Government.
We know, from recently released data, that there has been a 73 per cent increase in the number of Scots electing to go private for some treatments. What would you, as NHS Scotland chief executive, advise me to do if I was 80 and in pain, immobile and suffering from social isolation because I required a hip replacement and I had the means to pay for it?
I do not want anybody to be in pain and suffering. None of us—and none of our chief executives—wants anybody to be in that position. That is why we have focused on trying to reduce the longest waits on our waiting lists and on supporting people to live well while they are waiting. I do not advise people on individual choices, but our commitment is to do whatever we can in the face of many challenges, particularly the pressures on urgent and unscheduled care, to maintain the planned care programme and, in particular, bring down long waits as quickly as we can.
I have received correspondence from a constituent who has had to borrow money from their children to have a hip operation. That is unacceptable, but surely you can understand why people are choosing to do that in very challenging circumstances.
As I said, we do not want anybody to be in that position. We are working across the system to address that. If you talk to any chief executive across the system, they will say that they are absolutely trying to address that in the face of very challenging circumstances in which Covid has not gone away. In March, we still had more than 1,000 people with Covid in our hospitals.
The Audit Scotland report identifies that the creation of the national care service requires
“a significant unknown financial commitment to be met from the Scottish Government’s health and social care budget.”
As you are aware, ministers have paused stage 1 of the National Care Service (Scotland) Bill. Does that have any financial implications, in this year or in future years, for the health and social care budget in Scotland overall?
The budget for this year is set, and we will work within that. There will be a process to set the budget for future years. You are quite correct that the timetable for stage 1 of the bill has been extended, which has clearly been done with a view to enabling further consultation and identifying areas in which we can reach consensus. At this stage, it is very difficult to say what the financial implications of that will be, but we are committed to producing a revised financial memorandum.
The financial memorandum that accompanied the bill identified costs as being somewhere in the region of £1.3 billion, although that has been contested. The Auditor General said that he could not come to a final conclusion as to whether that number is accurate. Is there a concern that, if the total cost of establishing and operating the national care service—if it comes to fruition—is higher than that, we will end up cutting into health expenditure as a result?
We need to be clear that the financial memorandum did not contain a commitment to spend that money; there are business case and budgeting processes that need to be gone through. We would, therefore, need to undertake a process of scrutiny before committing that level of expenditure. As I have said, we are taking a moment to do more engagement with stakeholders, particularly the trade unions and local government, with a view to establishing how we might take the work forward. A commitment to co-design with people has always been implicit in the bill, and that makes it very difficult to pin down the exact financials.
Does Richard McCallum want to add anything?
Yes, I will add a couple of points. The financial memorandum contains a range of costs for the set-up over a five-year period. There was a relatively small sum at the start, in 2022-23—about £10 million—and, as indicated by the then Deputy First Minister, the plan was for spending of about £50 million or £60 million in 2023-24. Obviously, given the policy prospectus and what has been set out by ministers over the past week or so, we will review and scrutinise the appropriateness of the costs in 2023-24 and the projections for future years. That is key. Although there will undoubtedly be that scrutiny from the Government and Audit Scotland, we want to make sure that we think not just about additional spend but about reforming the system and about the change and improvement that we know are needed in social care. That will be the focus of the financial business case that Caroline Lamb mentioned.
The Scottish Government’s initial commitment was to introduce a national care service in the lifetime of this parliamentary session. It now seems that its commitment is to legislate for a national care service in the lifetime of this parliamentary session. For clarity, what timetable have you been instructed to work towards?
We are working towards the extended timetable for stage 1 of the bill. That will involve further consultation with stakeholders over the summer, and that will drive the rest of the timetable.
That is fine. We have talked about financial sustainability in the NHS, and you have identified reform and innovation as being critical to the long-term sustainability of the NHS in Scotland. Clearly, there was the meeting at which there was blue-sky thinking. At some point, we need to engage the public on what healthcare will look like in Scotland over the next five, 10, 15, 25 and 50 years and the timetable for that. How do you intend to engage with the nation and have that conversation about our national health service?
That is a question for ministers.
Okay.
I have a quick follow-up question that is based on the Audit Scotland report. You said that you agree with its findings and recommendations. One of the headline findings of the report is:
“The proposed National Care Service will place a huge strain on the health and social care budget”.
Do you accept that conclusion?
I accept that there is a requirement for social care reform. I have been clear that the commitment in the financial memorandum is not a commitment to spend money; we need to go through the budgeting processes and to work our way through all that. Audit Scotland raised questions about the requirement for social care reform, but there is also a question about how that is tackled in budgets. We are working to the budget that we have for the current year, and there will need to be further discussions about what budget is made available to the portfolio in future years.
The financial memorandum has been questioned by the Auditor General, and it was also questioned pretty heavily by the Finance and Public Administration Committee, which told you that you needed to go back and do your sums again and come back with a revised financial memorandum. I cannot remember a time when it was necessary for a Government department to revise its financial memorandum because it was seen to be so out of sync with what people estimated the costs would be. Do you feel embarrassed about that?
09:30
Clearly, we want to get this right. We accept that the bill is framework legislation, so there is a huge reliance on co-design in working out the detail. That is one of the challenges that we have had with the financial memorandum. However, as Richard McCallum and I have said, we have a process to go through involving robust business cases and the preparation of annual budgets.
I suppose that it also depends, does it not, on the model that is chosen? At the moment, it is envisaged that the national care service will, largely, be a commissioning model, whereas, at one time, we were told that it would be the modern-day equivalent of the foundation of the national health service, which is a very different model from the one that has been put forward in the bill.
As I said, the timetable for stage 1 has been extended, and there will be consultation on the best approach to take.
Welcome. It is nice to see you here. I want to ask about financial sustainability. We are informed that the Scottish Government’s health budget has increased by £4.4 billion since 2018-19, and that the total Scottish budget allocation for health and social care is £19.1 billion in 2023-24. That level of spending has been brought forward—it was expected to be that amount in a couple of years’ time.
However, NHS boards’ financial plans have shown that, of the 14 territorial boards, only three are expected to break even in 2022-23 if their savings targets are met, and seven of the eight national NHS boards are expected to break even if their savings targets are met. Does the Scottish Government have an update on the number of boards that broke even in 2022-23?
That is, obviously, still subject to audit, but we have had the year-end position from all 22 health boards now. What we expect—as I say, subject to audit—is that 16 of the health boards will deliver financial balance for 2022-23. Two boards will be within 1 per cent of their target outturn. As the Audit Scotland report states, that is an agreed parameter that we look to. Four boards will be further adrift in their outturn position, which is, in some ways, a similar position to where we were before the pandemic. There will be further follow-up scrutiny and work with them, particularly looking ahead to their 2023-24 plans.
That is where we are with the 2022-23 outturn. Appendix 2, I think, of the Audit Scotland report shows that, at that point, only three regional health boards were forecasting balance. At the start of the year, we often see boards reflecting a lot of the significant savings that they might make, but we do not necessarily see what happens as those savings start to be developed and delivered. Therefore, in relation to what is forecast at the start of the year, you will see that improvement as we move through the financial year. That is key for us now, as we look ahead to 2023-24 and as we work with the boards on their plans for the current financial year as well.
You mentioned Covid-19 and the specific expenditure that it brought about. Are there plans to support NHS boards to continue to reduce and monitor Covid-19 expenditure? If so, what are they?
I would not disagree with any of the points that Audit Scotland makes up front in the key messages section of its report on inflation, pay pressures, on-going Covid costs and rising energy costs. Those are absolutely true, and those costs are placing a pressure on our health boards that we have not seen in previous years.
On the Covid-19 challenge, for two financial years, we had additional Covid consequentials to support Covid costs. In 2022-23, that was stopped, so we have had to plan on the basis of not receiving those Covid consequentials in future. Therefore, it has been necessary, as we have budgeted and planned, to think about those Covid costs within the overall NHS budget, which is the £19 billion that you referred to. We need to work with the boards to challenge and scrutinise the specific Covid costs and, where possible, bring them down as far as we can, but we need to recognise that a number of those costs will continue.
Some of that will need to be managed within the boards’ existing resource—the baseline budget that they receive—but we will provide additional funding for certain programmes. For example, we are planning to allocate £140 million to support the vaccination programme in 2023-24. Similarly, we are planning to allocate a further £80 million to the on-going work on test and protect. Some of it will need to be managed within that core resource, as happens with other spend in the NHS, but we will provide specific allocations for some of it as well.
Is that a revision of the current brokerage arrangements between the Government and the NHS boards?
No. For two years, we paused brokerage arrangements. In the context of Covid and the uncertainty around spend and funding, we saw that as a sensible approach to take. We are now moving back into a scenario in which we want to be much clearer up front about budgets at the start of the year and, indeed, what we expect boards to deliver. The brokerage arrangements will remain in place. With that, it is absolutely key that the boards have a credible plan. If brokerage is required, there needs to be a credible plan to show how that repayment will be made, and we are working with the four boards that I mentioned earlier to deliver on that.
Does that mean that the Scottish Government still intends to, as was announced, double investment in the health capital maintenance backlog budget over the next five years, or has that been affected by those moneys having had to be allocated to deal with Covid?
The capital budget for health and social care is much smaller than the revenue budget. It is around £400 million to £500 million per annum currently. We intend—this remains the commitment over the duration of this parliamentary session—to increase investment to deal with our backlogs.
Some of that £400 million to £500 million is for our new builds, such as the national treatment centres that we have referred to, but some of it is to target our existing estate and the backlog there. We currently spend about £150 million to £190 million on backlog maintenance. Through to 2025-26 and 2026-27, we intend to double that figure beyond £300 million.
Does that take into account, as Mr Hoy mentioned, the ageing population and suchlike, and the extra moneys that will have to be generated to increase capacity?
I will jump in here, but Caroline Lamb might want to say more.
On capital and infrastructure, one of the key things that we need to reflect is the point about the ageing demographics. The design of hospitals and, indeed, our estates programme more generally needs to look at that wider service plan so that we are planning for 30 or 40 years ahead, as Mr Hoy mentioned.
Thank you very much.
I will take you back to what you said in reply to Bill Kidd’s opening questions. Did you suggest that the figure in the Audit Scotland report—that only three of the 14 territorial NHS boards were expected to break even—was just a snapshot at the wrong time?
I would not say that it was a snapshot at the wrong time. Boards developed a plan at a point in time and the numbers that are reflected in the Audit Scotland report show that. That information will have come from board papers.
As the financial year progresses, boards’ financial positions tend to improve, and that is obviously what we have seen in 2022-23. Although, as you say, only three boards were projecting balance at that time, we have seen boards’ financial positions improve over the final six months of the year. That is why, at the 2022-23 outturn, we have seen 16 of the 22 boards in financial balance.
Okay, but the Audit Scotland report came out in February, yet, just two days ago, in this Parliament, the chief executive of NHS Dumfries and Galloway told the Health, Social Care and Sport Committee:
“I have worked in the NHS since the 1980s. I am a finance director by background and I have never seen a position as challenging as this.”
He then went on to speak about
“an existential challenge to our current service models”.
He also said:
“technically, I cannot afford one in 10 of my workforce”.—[Official Report, Health, Social Care and Sport Committee, 2 May 2023; c 13-14.]
There is severe pressure on territorial health boards, is there not? It looks a bit more like the picture painted by Audit Scotland than the one that you have painted for us this morning.
Richard McCallum is reflecting the position that boards might start with, the presumptions that they make and the work that they do during the year to improve that position. The explanation that he gave you relates to 2022-23. The chief executive of NHS Dumfries and Galloway was talking about the position for 2023-24. I have no doubt that many boards are looking at a very challenging position going into 2023-24. That said, we expect to work with boards throughout this year, as we did last year. We have a national sustainability and value programme. Richard might want to say a bit more about that, and about how we support and work with all our NHS boards to identify and deliver savings and efficiencies to manage that through to a better position.
To be clear, I absolutely do not underestimate the scale of the financial challenge. As I said, I completely agree with the key messages from Audit Scotland about the on-going Covid pressures and the pay inflation and wider inflation that we are seeing. That is absolutely right. We go into 2023-24 with a significant financial challenge that we will need to work through. That is a reality of those system pressures. As Audit Scotland said, the NHS in Scotland is not alone in having some of the particular pressures that it highlights in the reports.
I will say two things specifically on the point that you raise about NHS Dumfries and Galloway and on where we are at the start of the year. First, NHS Dumfries and Galloway has particular challenges. I mentioned the four boards that are not in financial balance at year end; NHS Dumfries and Galloway is one of them. We are working closely with NHS Dumfries and Galloway on a review of its outturn position and the next steps for 2023-24.
Secondly, Caroline Lamb touched on the sustainability and value programme. That is absolutely right. There are a number of things in our system improvements and our efficiency programme on which we can and will need to go further, whether that is in our procurement practices or our work on agency spend and medical locums, on which we are working with the health boards.
I will add a final dimension. We are settling pay awards. That is an on-going situation in England, and there is a question about whether consequentials will come through. That presents challenges, which is understandable in some ways. However, the sooner that we get some clarity about that position, the better. That will help us with potential additional consequentials, but the position is still to be clarified.
09:45
Okay. Thank you. We will watch that with interest.
You used the word “challenging” a few times. It is worth noting, for the record, that the word used by the Auditor General is “concerning”. In paragraph 17 of the report, he said:
“The financial position of the NHS in Scotland is concerning.”
There is, I think, a suggestion there that things are not as they should be and that there are potential consequences for the kind of treatment that people can expect to get.
I will turn to what is, I suppose, at the heart of many of the questions that we are asking you this morning. How long does the Scottish Government think that it will take to clear the current backlog and fully recover healthcare services to a pre-pandemic level?
I will come to John Burns to provide some detail on that. For some time, we have been engaged in planning and scenario planning. As I explained earlier, particularly when we were going through the winter months—although it does not have to be the winter months—we saw peaks in Covid and surges in our hospital sector, which impact on planned care. We are looking at planning on a Scotland level, but we are also working with NHS boards to convert that planning into local plans, to see what more we can deliver out of the system in terms of productivity gain, the mobile units that I talked about earlier and other things.
John, do you want to say a bit more about that?
Yes, thank you. As has been said, we are working very closely with all the health boards across Scotland to do a number of things. We are making sure that we maximise the improvement opportunities that have been identified, whether that is the use of colon capsule endoscopy or cytosponge procedures. We are also looking at some improvements that we can make for out-patients when it comes to patient-initiated review, and ensuring that we have good referral triage at the point of referral so that patients are treated on the right pathway. That work is an important part of the improvements. We have already seen the positive impact of that work on capacity.
We are focused on other areas. There are good examples of maximising our day surgery capacity, but we are also looking to extend and enhance 23-hour surgery, which is where a patient stays in overnight but avoids a long in-patient stay. We are seeing that more surgical pathways can be delivered within that shorter stay, and, of course, that brings new capacity with it by freeing up the main theatres.
The other thing that we are seeing is that, as treatments change, we are able to use nurse practitioners to carry out some minor treatments, which also releases capacity that we did not have previously. Those are a number of the improvement initiatives that we are progressing.
We are also working with boards to ensure that we support and protect their work in planned care. That is a challenge for boards, of course, as they have to balance all the demands of unscheduled care and planned care, but we recognise the importance of ensuring that there is a level of protected capacity for planned care so that we continue the progress in treating increasing numbers of patients that we have seen in recent months.
Of course, we have the NTCs, and reference has been made to those excellent facilities. We will work to ensure that they are maximised and have protected elective capacity, so there is no potential for that to be disrupted by emergency and unscheduled care. That is an important facility for that maximisation. Those are national, not just local, resources. Again, we are working with boards to make sure that we can allocate those facilities appropriately, effectively and in as fair a way as possible. Patients are willing to travel: we hear that they will travel for care, and, of course, we will support that.
There are other areas in which we are looking forward. As you would expect, this year, we are working on our 2023-24 delivery plans for planned care. We want to ensure that those improvements are being maximised, but we are also refreshing and reviewing our modelling. As has been said, these have been challenging and difficult times in terms of managing and coming through Covid. Everyone recognises the importance now of doing all that we can to recover and to recover forward.
As part of that, we are looking at our modelling for planned care, recognising those improvements that I mentioned, looking at the NTCs and then looking at what multiyear delivery would be. That will not be addressed in just a couple of years. We therefore need to be clear and to be ambitious with delivery, because we recognise, as was said earlier, that there are people on waiting lists who need to receive their treatment. I know that clinical teams across the country are determined to do all that they can to make sure that we can do that.
We are in the process of working through those multiyear delivery plans, and they will inform our next steps. That work will be underpinned by maximising productive opportunity, working with our clinical staff and our clinicians to determine how best to do that, and by making sure that we are maximising and delivering on the improvements that will see us use the existing capacity as effectively as possible.
Mr Burns, you are using the language of progress and improvement but, to give two examples from the Audit Scotland report, the percentage of A and E attendances seen within four hours dropped from 83 per cent in December 2019 to just 62 per cent in December 2022, and paragraph 37 of the report states that delayed discharges
“increased to the highest level since 2014/15”.
That does not sound like progress and improvement to me. It sounds as if we are going not forwards but backwards.
My earlier remarks were referencing our work in planned care. I fully accept the situation for unscheduled care, as measured by the accident and emergency four-hour standard. No one finds that to be an acceptable position. Again, we are working to deliver improvement to that standard. We are working across Scotland on a range of improvement programmes. We are looking at high-impact change and at the discharge process to ensure that, as Caroline Lamb said, 97 per cent of people are discharged from hospital without delay.
Nevertheless, we are seeing longer stays in hospital when compared with the situation pre-pandemic. That, of course, contributes to occupied bed days and occupancy and then the delays through A and E. I would say, however, that we are also looking to deliver care differently. We have effective delivery of our out-of-hospital pathways. We have seen a doubling of our out-of-hospital bed equivalent capacity in Scotland, through the hospital at home service, community respiratory pathways and out-patient parenteral anti-microbial treatment pathways, where we are delivering that care in the community. We are looking at further ways in which to extend that through other pathways, such as that for heart failure treatment.
That is not only bringing additional capacity but enabling our acute and community teams to deliver care differently. That is an important part of how we improve the measures that you have described and how we improve the experience for patients. We are very focused on delivering those improvements. We are working with boards across Scotland. Boards have their own local improvement plans for making changes and for making improvements to that standard.
This next question might be for Caroline Lamb. One of the criticisms, or part of the analysis, in the Audit Scotland report is that one of the flaws in the NHS recovery plan, which was launched in August 2021, was that it did not come as a result of proper consultation with the territorial health boards. There was a commitment—perhaps a political commitment—that, within 100 days of the election in 2021, the NHS recovery plan would be published, but the consequence of that, according to the analysis in the Audit Scotland report, is that the health boards were not involved. Is that a matter of regret for you?
Clearly, we want to work with boards whenever we can. The recovery plan that was published in August 2021 was based on the additional capacity that we thought we could provide in the system. That was very much through new areas of work, such as the national treatment centres and work that the centre for sustainable delivery was doing on improvements to create more capacity, particularly in out-patient clinics.
We worked closely with the centre for sustainable delivery, which was in contact with all the boards around the opportunities for improvement. August 2021 was a point in time when we thought that we might be completely coming out of the pandemic, and we were then hit by omicron and had to go back much more into Covid management. There were three big peaks of omicron through 2021 going into 2022. As John Burns described, the work that we have been doing, and continue to do, is very much about looking at the picture at national level and how we can best use national resources, but that is very much predicated on our working with individual boards on their particular challenges and what we can do to support them.
I presume, however, that you agree with the recommendation in the report that the Scottish Government and NHS boards need to work “more collaboratively” in the future.
I absolutely accept that we need to work with our NHS boards, which are our key delivery partners, as are our integration joint boards in relation to social care. Richard McCallum’s teams work closely with boards on their financial position, and John Burns’s teams work closely with boards on their trajectories for planned care and for urgent and unscheduled care. We are working closely with all those partners.
Yes, but the conclusion that has been drawn by the Auditor General is that you need to work more closely with the NHS boards.
The report is from a point in time. If the Auditor General were to look at the range of working that we have with NHS boards at the moment, the improvements that we have made to the detailed planning guidance and the extent of consultation with the NHS boards before we issue that detailed planning guidance, I hope that he would accept that we have delivered a lot against that recommendation.
We have been told a few times that the report is from a moment in time, but it came out in February, and we are now in May, so it was not that long ago. Before I bring in Sharon Dowey, can I just ask whether you are planning to revisit the NHS recovery plan, which is one of the headline recommendations in the Auditor General’s report?
The planning that we are doing at the moment with boards is aimed at getting more granular detail on what we can expect to deliver and by when. In essence, we are going through that work in significant detail. We have learned a lot. When the August 2021 recovery plan was published, we all, perhaps overoptimistically, thought that we were through Covid. However, we were not, and we were hit by additional respiratory illnesses last winter as well. We are very mindful of the need to factor in different scenarios and the impact of those sorts of shocks on our planned care system.
Thank you.
10:00
Good morning. What steps has the Scottish Government taken to reduce reliance on bank and agency staff and the significant increase in expenditure on that?
We have a short-life working group, which is jointly chaired by one of our chief executives, Calum Campbell from NHS Lothian, and our chief nursing officer, Alex McMahon. They have been working through a number of measures that are aimed at reducing reliance on bank staff, but particularly agency staff, because that is where we get the extra premium expenditure. We have looked at measures to enhance recruitment into NHS Scotland. Clearly, the call on agency staff comes particularly when the system is under pressure, additional beds are open and we need to find staff to look after the patients in those beds.
It is important to recognise that, overall, the workforce in NHS Scotland has increased since the pre-pandemic period. Staff numbers are up by 9.5 per cent, and the total whole-time equivalent number in December 2022 was at 156,000, compared to 142,500 pre-pandemic, in December 2019. Within that, recognising that we are seeing real pressures on urgent and unscheduled care, we have had to open extra beds, which is leading to a reliance on agency staffing that is much higher than we would want.
Richard McCallum has already reflected the fact that we are the only nation in the United Kingdom that has not seen industrial action by healthcare staff. That is welcome in terms of our ability to manage the system, and it reflects the fact that we have made a good and fair deal with agenda for change staff. We have also put in place a number of initiatives that are aimed at supporting staff to continue to work in NHS Scotland or to do additional hours. Those include our retire to return policy, which is aimed at supporting people who have retired to come back and work on a flexible basis for NHS Scotland. We have also looked at allowing the boards discretion on how they use the pension contributions; that was before the changes to the tax implications of pension legislation were announced.
We have sought to recruit additional nursing and allied health professional staff through international recruitment. We achieved 200 additional staff by the summer of last year, and that encouraged us to allocate additional funding to enable boards to recruit up to an additional 750 staff from overseas. The early indications are that the boards have exceeded those targets, but we are working on that data and hope to be in a position to publish it shortly.
We are concerned that we should look quite broadly at entrances into nursing programmes. Alex McMahon, our chief nursing officer, has been leading work on bands 2 to 4 in agenda for change, with a view to ensuring that those staff have access to opportunities to develop and progress their careers, and that is linked to recruiting and creating additional band 4 posts. A huge amount of work is under way to ensure that boards have access to the staff that will reduce their requirement to go to agency and locum staff.
You have spoken a lot about recruitment. What are you doing to retain the staff that you already have? Many junior doctors seem to be taking a gap year when they complete foundation year 2, because they say that they are overworked and exhausted. I have figures showing that 15,000 NHS workers left the health service in 2021-22. You have said that numbers have increased to 156,000 compared to 142,000 pre-pandemic, but a lot of staff still seem to be leaving because they are overworked. What are we doing to retain the staff that we already have?
In a workforce of that size, we will always have people leaving through retirement and changes in circumstances. Clearly, we want to try to hang on to as many people as we can. Part of that has been about resolving the pay issues and getting to a point where we have made a really good pay offer to agenda for change staff. We have also encouraged all our boards. We have a national wellbeing hub, and around 200,000 people have used its resources. That is about signposting people to resources—there are lots of opportunities in that regard.
The point about career progression is also important. It is about ensuring that the people who want to develop their career in NHS Scotland have an opportunity to do so in a flexible way. We will always need to focus on recruitment, because we will always have people retiring but, equally, we are very concerned about hanging on to the people whom we have.
You mentioned pay, but there are also a lot of issues to do with working conditions. I spoke recently to some doctors. Some of their comments were about there being no compensation or time off in lieu of having to stay late at work. Some were expected to come in early. Some spoke about there being no rest facilities for night shift or when on call. Sometimes, if they get a chance to take a break, they have to put two chairs together to try to sleep. Some have been told that they cannot attend otherwise mandatory teaching sessions as workload and staffing do not allow it. The list goes on. Those trainee doctors will not stay if those are the conditions that they experience during their training years. Are all health boards involved in looking at working conditions for doctors?
Yes, absolutely. We want to ensure that all health boards have the wellbeing of their staff at the top of their agenda. That includes providing physical resources so that people can get a break.
We pay attention to the feedback that we receive specifically from junior doctors through the trainee survey. That is part of the overall work that NHS Education for Scotland does; it works with NHS boards where issues are identified around training programmes for junior doctors, and it looks at putting in place action plans to address them. There is a mechanism in the system for seeking to ensure that the quality of the training experience for our juniors is as high as possible. You are absolutely right: we want those people to have a great experience, because we want them to stay and work in NHS Scotland.
I understand why a lot of people who are involved in an intensive training programme feel that they need a bit of a break from it. A number of our boards—John Burns’s former board was one—have put in place arrangements for clinical development fellows, which enable juniors to take a year or more out of the quite structured training programmes. That perhaps gives people a bit more space to think about the specialties that particularly interest them and where they see their future. I think that juniors genuinely recognise that that provides them with a really positive experience.
John, do you want to say anything about your experience in NHS Ayrshire and Arran?
We recognised the need to develop that role. There are doctors who, as they decide on their training route, may want a bit more time. We created those posts to give them some time in which they could do further academic study or research, as well as provide service and, really interestingly, engage with the community. For example, we had individuals who provided services to local sports clubs. That is just an example, and I know that many boards now have such roles. That is an excellent way to retain doctors in Scotland. It gives people an extended opportunity to consider their next steps in their training career.
I have been out of NHS Ayrshire and Arran for a couple of years, but the feedback from those doctors was excellent. Having been supported and had that opportunity, they saw NHS Ayrshire and Arran as a board that they wanted to come back to in the future, perhaps for a consultant role. Those sorts of programmes add value and deal with the retention point that Sharon Dowey referred to.
Okay. Thank you.
Can you tell us more about what funding arrangements the Scottish Government is putting in place to ensure that Scottish students have access to places on medical courses that are offered by Scottish universities?
We would need to come back to you on the specifics of the funding arrangements. We can certainly provide you with that information.
When the Scottish Government puts out an announcement—for example, the one saying that we will have 800 more general practitioners—are there conversations between the NHS, the Scottish Government and the universities on a workforce plan, in order that you can see how many places you will need on those courses?
Yes. Taking the GP programme as an example, I will outline the things that we have done. We have increased the number of medical school places overall, but we also set up the Scottish graduate entry medicine—ScotGEM—programme at the University of St Andrews. It is aimed at people who have a particular interest in primary care. Through the training elements, we put a particular focus on remote and rural care, in recognition that that is an area that we need to recruit to. We set up ScotGEM to provide that pipeline through medical school, over and above the more traditional medical school route that is taken by students who want to train to be GPs.
We then had to increase the number of places in the GP specialty training programme. In 2022, the total number of places that were available in that programme was 326, and we recruited to 322 of those places. That is probably the highest fill rate that we have had for GP training for a number of years—possibly since records began, actually, but I will check that and get back to you. That is an indication of the fact that we have managed to develop an increasingly strong pipeline through to general practice. Such things take time: we have to encourage students through medical school and then provide the places and high-quality experiences through specialty training.
So, when you are doing workforce planning and you see a gap where you need more students on certain courses, the Scottish Government has conversations with the universities.
Yes—it is absolutely the case that conversations take place with the universities about the number of undergraduate medical places that are required. Then, NHS Education for Scotland works with the specialty boards on the projected requirements for consultants in each specialty. We have placed a particular focus on GP places to make sure that students who are coming through medical school have the opportunity to train in the specialties that we know we will need.
Okay. Obviously, there is free education in Scotland. One of the big issues is the talk of fewer Scottish students being able to get on to courses because the universities have to take on students who pay fees. I do not know how true this is, but I heard that in one recent dentistry course only three of the people who completed the course were Scottish and the rest were international students. I cannot say that that is a fact, but it is what I was told.
I know that you do not have them now, but could you give us figures showing how many places Scottish students get on medicine, dentistry and pharmacy courses, and an update on completion rates so that we can see how many Scottish students are completing courses in our universities and can stay on?
I definitely do not have those figures in front of me right now. We are dependent on the universities for that breakdown, so I will check with colleagues whether we can get that for you.
That is fine. Thank you.
Does the Scottish Government agree that the target to increase the GP workforce by 800 by 2027-28 is on track?
In my previous answer, I told you about some of the things that we are doing to build towards that. The increase in the trainee numbers in 2022 was really encouraging: 322 people are now on that three-year specialty programme, training to be GPs. We are building towards those numbers.
10:15We have also put huge investment into increasing the multidisciplinary teams around GPs—the pharmacists, advanced nurse practitioners and physiotherapists who support GPs, free them up and enable them to carry out the expert generalist role in their practices. We are up to 3,220 people having been recruited to multidisciplinary teams across Scotland.
We have the figure of 800 GPs, but that is a head count. I have heard that many GPs are now going part time. If you have 800 GPs who work five days a week, that is one thing, but if you have 800 GPs who work only three days a week, that would take, I think, 300 GPs off your figures. Do you have equivalent figures, so that it is not misleading to say that we have 800 GPs? If we recruit GPs and they all work part time, we are not actually getting full-time equivalent GPs into the system.
I absolutely accept your question. Clearly, we have an issue, particularly in general practice, with people wanting increasingly to work less than full time. I will see whether we have that information because, again, it would need to come from individual GP practices.
Okay. Thanks.
How successful has the Scottish Government’s international recruitment strategy been to date? Will international recruitment form part of future workforce plans?
Our international recruitment strategy has been really successful, to date. As, I think, I mentioned earlier, we had recruited 200 staff by August 2022. That encouraged us enough to put in additional investment to enable boards to recruit up to an additional 750 staff. Early indications are that we will certainly achieve that. Some boards have taken the opportunity to go further. Clearly, that, too, is a resource that they can balance against the need to use agency staff. The feedback from many NHS boards is that they find it to be a helpful and useful resource. However, that is not uniform across Scotland; in some areas, especially where housing is a challenge, it has been more difficult to bring people in from overseas.
There is an extra premium when you take on international staff. Are you looking at or tracking retention rates of international staff compared with those of domestic staff?
Yes. We are looking at how we can ensure that we keep international staff, albeit that they might want to move around Scotland.
Okay. Thanks.
I will bring in Craig Hoy in a second. We have spoken about the number of GPs, and about recruitment and retention and so on. Last year, the committee was quite exercised by the broader picture of GP data, which we took up with you in correspondence. I can characterise it as follows: on the one hand, we have GPs saying, “We’re seeing more patients than ever”, and, on the other hand, our postbags are full of correspondence from people saying, “I can’t get an appointment with a GP.” We were quite keen to have transparency on that. We certainly corresponded about an oversight group that you had put together that was, I think, an attempt to get into the granular detail. Can you update us on that work?
Yes. I share your keenness to have access to granular data. We have a wealth of data on our acute sector performance, but we have had to put in place mechanisms to build our data on other parts of the system. Social care is one such area, and primary care is certainly another. When we met last year, Sir Lewis Ritchie was chairing an oversight group that was looking at data in primary care. Public Health Scotland has been working on mechanisms to make that data available from individual GP systems. Although it has produced some publications on GP activity and has managed to make the data available at national level and NHS board level, we have some issues with the quality of the data because things are coded differently in different general practices. There is still some work to do on that.
We have started the roll-out of the next generation of information technology to general practices; we hope that that will help to improve ease of extraction of data from GP systems and that it will give us a chance to start with a clean slate on how data is coded. However, it is extremely challenging. I talked earlier about the multidisciplinary teams and how we need not just to be able to track activity and patient contact from the GP perspective, but to recognise that it is often much more appropriate for someone to see a physiotherapist or pharmacist than it is to see a GP. Again, we all share the desire to understand the data and, therefore, to understand where our opportunities for improvement are.
Okay. Obviously, as the Public Audit Committee, we are interested in the public accountability of the service, and the only way for us to achieve that is to have the data and that degree of transparency. You might share our frustration, but I re-emphasise to you that we think that it is extremely important, because, for many people, general practice is their access point to the national health service.
I want to follow up on the deputy convener’s question on staff retention. Last year, I attended a round-table meeting with the Royal College of Nursing, the chief nursing officer for Scotland, the former Cabinet Secretary for Health and Social Care and front-line nurses. One thing that struck me was that simple but, I presume, effective mechanisms such as exit interviews were not necessarily being routinely deployed throughout the service. Perhaps I could have confirmation that you now use such tried and tested practices more. Do you have an adequate handle on why people are leaving nursing, for example? How responsive are you to the key messages that you get about why people leave the service?
We can do more in order to be clear about the reasons why people choose to leave nursing and, thereby, get a better understanding of what more we can do to keep them. We recently established a nursing and midwifery task force that is looking at a number of issues with recruitment and retention. Opportunities—how we can best use our nursing and midwifery workforce—are among the things that the task force is looking at.
Would it be fair to say that, at this point, you are not doing enough to capture the information on why people are leaving?
We could definitely improve the data that is available to us, at board and national levels.
Thanks. I turn to Bill Kidd for the final series of questions.
I have a wee question about reform and innovation and how they are being used by the Scottish Government and NHS boards. You mentioned, I think, the need to monitor public awareness and acceptance, and ways of assessing services to make sure that they are effective—[Interruption.] The way I am coughing, I might need to go to hospital. Hold on a second, if you do not mind. I like a bit of melodrama.
Given that the public need a realistic understanding of what is being achieved, and given the need to try to involve them in difficult choices, how effective has the Scottish Government’s redesign of the urgent care programme been in reducing the number of people who self-present at hospital? What feedback has been received from patients about the service changes that have been made?
Do you want to take that one, John?
Yes, I will. The redesign of urgent care has been a successful programme, and it is an area that we need to continue to evolve and develop. It has been successful—having looked at the period of the pandemic and made sure that we are comparing effectively, we have seen a reduction in self-presenting attendances.
The intention was always to have a reduction in self-presenting attendances, and a number of factors have supported that. The first of those is the work that NHS 24 and NHS Inform undertake. In March, around 12 million people accessed NHS Inform and, from it, were able to access self-help guides. We have also had effective communication with the public over time about the “Right care, right place” initiative on how to access services, whether through people’s general practice—it could be through a nurse, pharmacist or physio—or their community pharmacy. There has been excellent progress made in respect of the important role that Community Pharmacy Scotland plays.
Through the redesign of urgent care, we have introduced flow navigation centres across every board in Scotland, so that individuals can be referred by NHS 24 to a flow navigation centre and then be either directed or redirected to the right care, which is not always an accident and emergency department.
Finally, I want to mention the excellent work that the Scottish Ambulance Service has done on providing clinical advice when people call, and the ability of its skilled paramedics and staff to manage and provide care at individuals’ homes in order to avoid conveyance to hospital and to get support through the flow navigation system via peer-to-peer conversation.
All those factors have made an impact and have allowed us to provide care differently, and to provide care that avoids unnecessary admission to hospital or attendance at an accident and emergency department.
We must assume that this has a lot to do with monitoring public awareness of the changes and the public’s acceptance of new ways of accessing services to ensure that they are effective. We know that professionals see how the changes that have been made work, but is public awareness as great? Can it be improved so that the care and wellbeing portfolio can bring about the reform that is necessary to improve public health outcomes? The monitoring and reportage that comes from that should give us all comfort that the changes are achieving what they are meant to achieve. Are the public sufficiently aware of the changes?
Yes. Consistently, for a number of years, we have used public messaging and marketing to signal changes. In the past, we have done leaflet drops to every household in Scotland, setting out the range of services. Most recently—I should have referred to this earlier—we introduced the NHS 24 Online app, which gives access to self-help guides. We are developing that; it offers more opportunity to make services more accessible, as people now tend to use apps more readily to access information. We will continue that important development. We also know, through evaluation, that the marketing has been impactful in terms of how people across Scotland use and access services. From our data, we can see a shift in how care is accessed.
There will always be more that we can do to measure the impact. We want to stay sighted on that because, as we make progress on urgent care, there will be more that we can do on pathways of care in order to support people in different ways. We need to continue to ensure that our understanding, data collection and reporting of the impacts match and follow the changes.
That is helpful; thank you very much.
10:30
That pretty much brings us to the close of the session. There are two things in the report that I want to highlight, on which I would welcome your views. One is the agenda for reform. The clear message from the Auditor General is that the level of funding for the NHS is at a record level—£19 billion—yet we continue to see suboptimal outcomes. I guess that the debate about what we need to do to change and reconfigure services is central to that.
Some of this goes back to the Christie commission of over 10 years ago and what it said about having a preventative agenda and taking a broader view of public health, rather than just having a view of the institution of the national health service. That rests on public debate and engagement, so, in closing, it would be useful to find out your perspective on that and what your plans are in that regard.
The other issue is related to that. One of the key recommendations in the report—you said that you accepted the recommendations—was that you publish annual progress updates on service reform. Is it your intention to do that?
I absolutely agree with your analysis that this is about tackling the broader public health issues, but as I said earlier in response to a question from Craig Hoy, it is also about how we provide services differently, how we use innovation and technology to provide services to people in their homes, and how we provide services in a more preventative way. The closed-loop diabetes system is a clear example of how we can prevent people’s health from deteriorating by using relatively simple technologies.
We already publish some of our progress in relation to innovations. After the pandemic, we produced a publication on how we had used digital health technologies to deliver services differently during the pandemic. Many such things remain in place; the huge increase in the use of NHS Near Me is an example. It is very useful for us to make available the evidence on the impact of that innovative work—[Interruption.] I am sorry; I am suffering from Bill Kidd’s complaint. Whether that is in the form of an annual report or something that focuses on various areas of activity is something that we want an opportunity to think about.
I take it from that that your answer is not yes. Do you accept the recommendation from the Auditor General?
I accept the recommendation that we need to be able to publish information about the impact of innovation and how it changes the way in which we deliver services. We will need to reflect on whether that needs to be done through a dry annual report or there are different ways of doing that.
I am sure that the Auditor General was not suggesting “a dry annual report”, but was, rather, suggesting something that would be informative and would help people to understand the progress that has been made. We have highlighted some of the areas where we have concerns, but as you said at the start, some extremely critical work is going on—thanks, not least, to the workforce. The committee adds our thanks to yours to the staff who do such incredible work and provide services day in, day out and night in, night out.
On that note, I close this morning’s session. Caroline Lamb, Richard McCallum and John Burns, thank you for your input, which has been very useful. You said that you might get back to us with a bit more detail on some areas; that would be most welcome.
10:34 Meeting continued in private until 10:59.