Health and Community Care Committee,

Meeting date: Wednesday, May 2, 2001

Official Report 291KB pdf

---

Budget Process 2002-03

Good morning. I welcome Professor Hanlon and thank him for coming to the committee to assist with its deliberations on the budget. Would you like to make any comments before the committee asks you questions, Professor Hanlon?

Yes. Andrew Walker was good enough to tell me that there would be an opportunity to set the scene.

Massive debates are going on about how best to spend money in Scotland to improve health. It is gratifying to see so much scrutiny. I was struck by a letter in The Herald this morning from a Dr Moore from Inverness-shire. Dr Moore is a general practitioner and is, doubtless, very informed. He makes a number of very good points in the latter part of his letter, but I am very concerned that he begins his letter by saying that health in Scotland is getting worse. As evidence of that, he points to the increased number of cancers, admissions for heart disease and the rising tide of diabetes.

He is right about the rising tide of diabetes and we need to be concerned about that. However, there are more cancers because people are living longer and are healthier. They live to ages at which they can get more cancers. That is terribly good in a way, although the fact that they end up getting cancers is of concern and it is a care issue that we need to address. There are enormous complexities, even for someone in general practice, for example, who deals with such data.

I understand that my good friend, James Dunbar, spoke to the committee last year about Finland. I am a fan of what is going on in Finland, but simplistic conclusions can be drawn. Forth Valley Health Board's annual report shows improvements in heart disease figures that are every bit as good as what Finland has achieved, but no summer schools are run in Stirling on how that board has achieved such improvements. The committee will take my point.

Many things in Scotland are getting better. Heart disease figures are getting better and cholesterol and AIDS-specific death rates are falling. The story can be spun positively. Alternatively, rising obesity, diabetes, asthma, depression and suicide in younger men can be pointed to. The story can be spun either way. In such a complex situation, we do not want to over-elaborate; people need to understand what we are doing and why we are doing things. However, we do not want to grasp simplistic solutions to complex problems. That is my main point.

Thank you for coming to the committee, Professor Hanlon. What are your views on the current level of expenditure on health promotion? What are the most pressing needs in developing health promotion activities? Will you comment on the disability proofing of any of the plans, perhaps with particular reference to categories such as deaf people? We know from a Greater Glasgow Health Board report that 23 per cent of deaf or hard-of-hearing people leave GP's surgeries without knowing what is wrong with them because of a lack of visual help. Furthermore, there are major communication problems in hospitals.

On Dorothy-Grace Elder's first question, if you are talking in narrow terms about expenditure on a professional activity called health promotion, the amount that is spent is probably about right at the moment, because it is a small part of our entire endeavour to improve health. For example, in last weekend's British Medical Journal, an article from the University of Glasgow showed that students of my generation have lower blood pressures than those who were students 10 or 15 years previously. That is almost certainly due to post-war improvements in housing and other factors from which I, and the rest of my generation, have benefited. The period when people are born affects their blood pressure levels when they are students and after. As a result, investment by the post-war Governments yielded a benefit that could be measured 20 years later and which is still having an effect on our lives. Such impacts on health often take that length of time to manifest themselves.

As a result, the big question about Scotland's health does not centre on the amount of expenditure on a narrow area called health promotion—that activity is carried out professionally at the moment—but on how that spend impacts on the way we use the rest of our national and local resources. There is less cause for satisfaction about whether we are having as much of an impact on the big factors that influence health as some of our European counterparts.

What are the most pressing needs? Furthermore, could you address my point about disability proofing, particularly in relation to deaf people?

The most pressing need is to find some effective methodologies to confront the effects of social exclusion on health. Although there is some evidence of modest improvement through social inclusion partnerships, demonstration projects and various initiatives from the Westminster Government, there is much more evidence that the health inequalities in Scotland are continuing to worsen. It is probably still quite early to make such a judgment; however, we are certainly seeing no rapid improvements. Although this is an old story for the committee, we cannot lose sight of that issue.

Scotland's problems reside largely in the 20 per cent of people who live in relative poverty. If they were taken out of the population figures, we would compare rather well with other European countries. As the majority of the country's health problems lie in Strathclyde and other pockets of deprivation, we will not crack Scotland's health problems until we solve that problem.

As for disability proofing, one of my masters students was involved in some of the work that Dorothy-Grace Elder quoted, so I am quite familiar with it. Frankly, the situation is a scandal; it is as simple as that. That we have not focused on those problems is down to a historical legacy. It is not right that someone should have poorer access to a health service facility because they cannot hear what is being said or cannot see what is being done to them.

However, there is no easy answer. Dorothy-Grace Elder mentioned deaf and blind people; I have a slightly better example. I was involved recently in the case of a young man who has muscular dystrophy and who needed to be examined by his GP—it does not matter what for. Because the young man is now older and bigger, he needs the use of a hoist to get onto the couch. His GP told him, "There's nothing I can do about it. I don't own these premises; they're rented from the health board."

Shocking.

It is shocking. The GP had not thought the situation through; he did not know that the social work department would have lent him a hoist for the afternoon. However, the GP felt disempowered. I suspect that he had had such hassles over the years with his health centre that he felt that he could not do anything to make things work better. The issue of staff disempowerment is at the heart of the problem. Many members of staff want to do things better, but they are frustrated because they feel that they are part of a big system and cannot get access to translators, signing and so on.

There are only 16 fully registered signers in Scotland. The deaf and hard-of-hearing population is about a seventh of the population of Scotland. At hospital level, there does not seem to be deaf awareness training. There are many examples of consultants coming into a ward and speaking nicely to everyone else who is about to have an operation, and then going up to the bed of the deaf person and just making a thumbs-up gesture.

Indeed; and with the population getting older, that problem will grow. I concur—but I am only as familiar as members are with the research. We are only just taking the lid off the problem, and we probably need to go back to base 1 to think about how to solve it.

At the moment, the Executive is putting money into three demonstration projects. Should we wait for those projects to be completed before we go out and spend money on the areas that are concerned, or should we be budgeting now? Do you have any evidence that the Executive is budgeting now to roll the projects out if they appear to be successful? Is there any forward planning on that that you have found, either in the health improvement plans or in the community plans, as they will be known?

The short answer is that I do not think that we should wait. We are rolling out the main lessons. The main evidence that has informed the work on heart disease and early intervention is accessible by other parts of Scotland, and other parts of Scotland are considering their versions of the lessons that have been learned. The major question that the demonstration projects ask, and have to answer, is whether additional expenditure—above the level that is normally made available to health boards—yields markedly greater results. We should wait for the answer to that before we throw more money more intensively into defined areas. I do not know the answer to the question now—we need to wait for it.

Those projects are obviously being evaluated, as they are demonstration projects; I presume that they are being monitored carefully. What about the more general approach, to which you alluded in your first answer, on healthy living centres and community schools, both of which are supposed to have an input into deprived areas and tackle the issues of social exclusion?

Some of the smaller-scale projects are doing well, and some not so well. I think that our biggest lack is of larger-scale interventions. Let us consider the various housing projects in which Scotland has invested over the years. We do not know what impact those have on health. We do not and will not know what impact the whole social inclusion partnership programme, which is a large programme, will have. If you ask me whether a breakfast club works, I can say that work has been done that will tell you the answer. If you ask me about exercise referral schemes, I can say that evaluation has been carried out on them. Usually, such schemes work a little; they have marginal effects. What we are really ignorant about is the results of the large programmes of expenditure and the impacts that those have on health.

Do you think, therefore, that the Executive, through its central funding, should ensure that the health impact of the social inclusion programmes is being evaluated?

I will say something controversial in reply—although I have not thought this through fully. I will quote Sally Macintyre of the Medical Research Council unit at the University of Glasgow. She makes the point—which I am also thinking about and which I will now put into the committee's court, so that members can think about it—that, to take the debate out of the Scottish context, if a lot of money is to be spent on health action zones, and given that health action zones are being set up in 30 locations around England and Wales, they should be randomised. If they are being allocated fairly arbitrarily anyway, why not randomise them and do a proper study and consider the areas that got the additional investment, compared—over a defined time scale—with those that did not?

If they really work, health action zones could be set up in other areas; if they do not work, then it is discovered that money has been wasted, but only in some areas. That does not mean that the problem has gone away and can be ignored; it means that that is not the route to go down. We should consider whether the big blocks of the Scottish Parliament's expenditure should be subject to a similar method of appraisal.

I want to probe further on the evaluation of health promotion schemes. We all think about the schemes that we know, for example the west of Scotland coronary prevention study, which was long and involved, and we think about the time scales and diverse outcomes of the schemes. I know that the evaluation process is difficult, so can you suggest ways in which targets can be set, so that evaluation is more easily definable? Are you satisfied that the data that come out of the studies, particularly the more long-term, diverse studies, are sufficient to monitor the studies effectively?

The answer to that could be the subject of a two-hour seminar, but I will try to give you a 30-second reply.

Take the example of smoking. The amount of people who smoke in Scotland has fallen by 1 per cent or 1.5 per cent every year for the past 15 to 20 years. That is a remarkable success, particularly because the number of smokers in eastern Europe and Asia has been rising. That has happened not by magic, but because of action that we have taken. What action, however? Was it the Health Education Board Scotland campaign? Was it work place schemes? Was it the smokebusters club? When an individual evaluation is conducted on any one of those initiatives, it is found that each had some effect, but that the effect was usually quite modest. Sometimes, it can be found that the initiative appeared to have no effect. However, the combined influence of all of the initiatives of the past 20 years has reduced the amount of the population who smoke from the mid-40 per cents to the high 20 per cents. That is a considerable success, but I cannot say which specific initiatives caused it. That is what the Parliament will have to grapple with.

If you asked me whether I could give a defined scientific answer to the question of how we can confront inequalities in health, I would probably have to say no. Political judgments that are made on the best scientific evidence we can muster will have to be made. That is not an excuse for not doing good science with what is left, but it would be oversimplifying a complex problem to say that we can ever get to a point at which we are able to determine the two or three measures that would remove health inequalities.

I understand that it is hard to evaluate individual studies but, in that case, how is the spending on a particular project justified?

We can do two things to add rigour to such an exercise, if not proof. We should conduct defined scientific studies on particular interventions. One might ask whether a Starting Well intervention increases parenting skills and improves child health and child education. Such questions have defined answers and we are in the process of working them out.

We should also measure a sufficient number of broad outcomes in the areas about which we are most concerned. For example, if we are worried about Pollok, we should measure a series of indicators around the physical and social environment, health and well-being functions. You should be able to ask me or people like me how Pollok is doing and whether the action that is being taken to help Pollok is making a difference. As I said a second ago, I might not be able to say what is making a difference, but we should be able to give you accurate data on whether we are moving in the right direction. The neighbourhood statistics project, which the committee will be aware of, will help with that. It is an important endeavour that needs proper encouragement and scrutiny. Once those data come out, we should be able to point at any local authority area, neighbourhood scheme or whatever and ask what progress is being made. That will add to our knowledge and our ability to scrutinise.

Earlier, you mentioned Forth Valley Health Board. Did that health board do anything specific that led to better health outcomes?

I do not think so. What happens in Forth Valley Health Board's area is an indication that middle Scotland—I call it that because it is geographically in the middle of Scotland—does not have the extremes of deprivation that some other parts of Scotland have and is doing quite well. It is doing well because of all the things that we have been doing. The success is due to a combination of GPs giving advice, health visitors doing their good work, schools doing what they do and so on. All the social programmes that we are working on are having an impact on issues such as heart disease. We must praise them for that as well as acknowledging the problems that we have.

People in that health board area have not been eating more berries and so on, have they?

No. I am not sure whether a berry initiative could be done in Scotland. We should learn the lessons from Finland that are applicable to Scotland rather than simply imagining that we can transplant the initiatives wholesale.

The Finns tried to take fat out of the food chain. However, even if you take all of the fat out of milk and feel good about drinking low-fat milk, you will not remove fat from the food chain if you then go and eat luxury ice cream, which is what the cream in Finland is made into. If Scotland wants less fat in its diet, it has to remove fat from the food chain. That will not happen by accident or by wishful thinking; it will happen because of a combination of consumer choice and the production factors that are outlined in "The Scottish Diet: Report of a Working Party to the Chief Medical Officer for Scotland". We are probably not pushing through the recommendations of that report with the vigour that we might.

There will be a public health input into community planning and health partners will be involved in that plan. Will that bolster those plans sufficiently to ensure that we can secure the outcomes?

I agree that community planning is an important and terrific opportunity for public health. It brings local authorities and health boards together, and we should maximise it. It is an advance. There are some things that we can do, but other things require national co-ordination, such as the issues in "The Scottish Diet". People must look at what is happening to the diet of Scotland, so that the benefits that we are beginning to see in places such as middle Scotland are pressed home in other parts of Scotland. Community planning is part of the answer, but it is not the whole answer.

While local health promotion activities must be tailored to needs, there appear to be large variations in spending on health promotion between health boards. How does that tally with your perception?

I saw those data, and I was surprised by them. They have to be examined to see what is being counted in and counted out in different parts of the country. Since taking up my new role at the Public Health Institute of Scotland, I have travelled around Scotland meeting lots of people. My impression is that health boards do different things. There are different styles and priorities, but there is a core that is similar; for example the commitment to social inclusion, local partnerships, community planning and targeting key groups, such as community schools and young people. That core is common throughout the country, but there are issues that are particularly pertinent to Dumfries and Galloway, Glasgow, or wherever.

I am not sure whether I believe that there is as much of a discrepancy in spending per head of population on health promotion as it would appear. Some boards are counting more in and others must be counting more out, because when one goes round it does not seem that Dumfries and Galloway is spending markedly less than any other health area.

You have been invited along today as part of our examination of the budget process, because we are committed to better public health in Scotland. You have talked about many things—for example, social inclusion partnerships, deprivation and inequalities—but you have not mentioned healthy living centres. I was shocked when I received a copy of a 22-page application from doctors on Skye to the lottery new opportunities fund. I will not go through it with you, but it is about patients and self-help, health empowerment, information technology, professional support, bringing together the voluntary sector, and heart disease, stroke and diabetes. The document is about stopping telling ourselves that we are sick, and taking ownership.

There is an energy within the document, which comes from a remote part of the country. When you talked to Janis Hughes about randomising the siting of health action zones, I could not help thinking that it would be wonderful to include the Isle of Skye in that experiment.

The local doctors spent more than three days submitting the application, but it was rejected because it did not fit strategically. I am not a medical person, but what are the local barriers to giving health promotion higher priority? It is difficult for us to find out what is spent on public health, because so much depends on lottery funding. It is not much of an incentive to local doctors if they pull together but are rejected. When people want to make a commitment to public health, they get this kind of treatment. I am sorry for being negative, because you put forward a positive point of view, but I want you to be aware of the barriers that exist in Scotland.

All I can do is agree that it is terribly dispiriting. One of the things that the committee could do is define what should go into what we call core public health promotion expenditure, so that that can be monitored over a longer period of time. That has never been asked of health boards. It is a simple thing that would increase transparency.

It is difficult for us to find out what is spent on health promotion and public health when there are doctors who have to depend on lottery funding to achieve national priorities. I ask for your advice. How can I go back to my constituent and say that the Scottish Parliament is committed to public health, although that application has been rejected?

I hesitate to comment on that specific application. However, I would have thought that people who are motivated enough to get such an application together might be able to make quite a lot of those things happen without the lottery funding. There are good examples of people in all parts of Scotland who have failed to get lottery funding, but who have made 40 per cent of what they wanted to achieve happen, and got 60 per cent of the impact.

I am not trying to belittle the issue that the Skye doctors are confronting and I will not comment on it because I do not know the details. However, it seems to me that the sorts of things that Mary Scanlon mentioned are important to every community in Scotland. We ought to get that kind of activity going in every community. I recently visited a GP down in Dumfries and Galloway who had equipped part of his surgery as a small gymnasium. In such a rural area, that is the only access that some of his patients could get to such facilities, and he had made that investment from his own practice fund.

There are all sorts of innovative approaches that can be made. I am not disagreeing with Mary Scanlon—I agree with the fundamental point, but I would encourage the doctors who contacted you, if they can, to do as much of what they propose within the resources that are available.

Some of the improvements are not resource-based, but spring from new ways of working and from working in partnership with other organisations. A lot of what Mary Scanlon has described is actually happening throughout Scotland, and people are sharing good information on how to go about doing that.

Primary care in Skye has a good track record of doing such things. That is presumably why those doctors were able to put such a good project together.

The GP has already spent more than £20,000 on the project, so the financial commitment exists.

I return to my other question. Do you feel that there are any local barriers to giving health promotion higher priority that we should be aware of?

There are two very different things. All too often, the old conundrums of the health service and the pressures on it swamp the agenda and take people's eyes off the longer-term goals. Even issues such as disability access are affected. The firefighting just swamps managerial time, and that is a real barrier.

The second issue is more ephemeral, and has to do with just what Mary Scanlon was alluding to when she acknowledged the good practice in Skye. A sense of "can do" is needed, among staff and among patients. I firmly believe that we need to raise our sights and encourage each other to do what is achievable. I am trying to be positive and I am not trying to downplay the difficulties, but failure to have a sense of "can do" is a true barrier to improving health in Scotland.

I will try to stay on a positive note. I read Highland Health Board minutes that said that the board had appointed five public health practitioners. I am not sure whether they are nurses or doctors, but they will be allocated to local health care co-operatives. Is it necessary to have new people? Should not we be using the skills of the people who are there already? Is that the way forward throughout Scotland? Do we need additional public health practitioners?

I do not know for sure the answer to that question. That initiative arises from the nursing review, which did the fieldwork. The conclusion of the review was that that skill was lacking. It is a question of bringing people together and mobilising staff, particularly in the nursing work force. You will have heard the phrase, "It's happening already." Yes—there is lots of it happening already, but it is not happening systematically, and that is what will be key to the success or otherwise of the new public health practitioner grade. If those people can work systematically, they will be a great success. If not, we will have to think again, but they have three years to experiment.

How will those public health practitioners drive forward the agenda?

That will vary from place to place. For example, there are the demonstration projects, which Richard Simpson talked about. Great efforts have been made to bring pilot projects, such as Starting Well, to Glasgow. Who can take the lessons that are learned from such projects and apply them locally? Who can orient local health visitors to a new way of working and encourage them, for example, to abandon the old practices of weighing babies and measuring their heads and to try new things? Skills and drive are needed to make such new initiatives happen. That is the sort of work that the public health practitioners will do.

The public health practitioners will be judged by whether they can make new, innovative and modern things happen in places where such things were not happening before. If they can, they will be a great success; if they cannot, we will be back to asking whether we can use the existing resources more effectively.

Will criteria be put in place to measure the outcomes of the public health practitioners' input?

Our organisation, the Public Health Institute of Scotland, is just being established. We are recruiting staff at the moment, but they will be in post in the next month or so. We have called a meeting of practitioners and we are considering a way of evaluating what the practitioners will do and what the outcomes will be. I cannot report the detail of that, because it is yet to be formulated, but it is on the agenda.

Do you not have a job description yet?

A model job description is available.

Everyone accepts what you say about the importance—if we are ever to improve the health statistics in Scotland—of the spending programmes on housing and social inclusion and to tackle and eliminate poverty. I will go back to what you described as the narrower or professional definition of health promotion and what we spend on it, which you said you thought was adequate. Is there a danger that spending from that budget is likely to benefit the most affluent and motivated sections of the population and to miss the poor?

Yes.

Could you expand on that?

What you have outlined is a perennial problem in public health. The implementation of any new ideas, ways of thinking or way of working requires effort. Of course, if someone has a good job and has resources, their ability to take on board such new concepts is greater.

What you outlined is a problem, but I reassure you that every public health department in Scotland is genuinely committed to targeting its activity at those who are most in need.

Diet, after smoking, is probably the most significant contributor to deaths from the big three in Scotland and most affects the poor. A constituent recently came to me because he had been refused a loan to purchase a cooker. I took up the case with the Benefits Agency, which told me that direction 3 of the social fund directions prevents any loan being given to any individual unless it is the only means by which their health and safety can be preserved. The Benefits Agency—and indeed the appeals tribunal—has ruled that a cooker is not essential to a single person who lives alone because they have access to takeaway meals, salads, fresh food and long-life foods.

To me, that seems counterproductive to what we are trying to do in Scotland. What relationship is there with Westminster that would allow you to say that those rules should be changed because they are making the poor in Scotland ill? There is no point in you spending money on health promotion if the man cannot get a cooker and cannot access decent food.

We have various networks in public health to make such advocacy points. I would be happy to feed that example into the networks, if that would make any difference.

Unless we can join up the policy, advocacy and advice go nowhere. I can only agree with you on that. I assure you that the public health and health promotion community in Scotland is genuinely committed to targeting those who are most in need, although it acknowledges the problem that you raised.

I am all in favour of removing fat from the food chain in Scotland, despite my appearance. However, producing leaflets and distributing them through, for example, libraries will not help the poor to remove fat from their diet.

I am not suggesting that we do that.

Should not we be spending money on establishing food co-operatives and helping them get access to healthy food?

Absolutely. I do not want to be misunderstood. The James report on the Scottish diet deals with all that. It is the best analysis that we will get of the problem of food in Scotland. It uses the phrase "from plough to plate".

In a poorer community, issues such as food co-operatives and what we do in school dinners are key. Giving people leaflets is certainly not the answer; everyone knows that. I was trying to say that it is necessary to join things up. The Scottish diet action plan is supposed to be about addressing production, distribution and promotion, as well as about supporting individuals and linking that to social inclusion.

There are areas for which we have good analysis and a good set of solutions that we need to drive home to people. I am not convinced that we are driving home even some of the well-established matters as well as we might.

The fundamental problem for the Executive is its relationship with the health boards. The Executive gives the health boards the money and, until now, it has performance managed them on finance, but the bottom line is, "Do what you want with the money".

In relation to the public health agenda, are you comfortable that there will be adequate performance management of the new money that is coming through?

To be honest, no, although I am not being critical when I say that. I will not be comfortable until the broader determinants of health are included in the performance management framework of a health board and its accompanying local authority and both are held to account. For example, housing and diet in poor areas should be key issues. Until indices of improvement in those key areas are part of the accountability framework, for both the council and the health board, who will ensure that the community plan and all the other fine documents hit their targets? We should do something about that.

So, you think that the community planning process should be involved—

I would include performance management in health plans, community plans and the accountability mechanism—Gerry Marr's accountability framework and the Audit Scotland accountability framework for local authorities. Joint targets could be set on key health areas around the determinants of health; that would draw the agenda sharply into focus. Those areas are as important as waiting times or overspend in acute trusts when we come to an accountability review.

Given the Arbuthnott funding and the specific allocations to cover deprivation, I feel that there is a greater requirement for clarity, within the health boards in particular. Greater clarity would ensure that funding that has been allocated centrally filters through to deprived communities. There may be an opportunity for such clarity and for performance management to be undertaken following the conclusion of the budget process. Is it clear from the budget process that that opportunity exists?

I agree that it is clearer—we have made progress on that.

I am not sure whether my role is to challenge the committee, but it seems to me that the newspapers are full of reports of parliamentary debate on issues such as expenditure in acute trusts and waiting times. Let me be clear: unless those important issues are dealt with correctly, the health service will never move on to the agenda that we are talking about today. I would love people to be as exercised about the rising rates of suicide or of people who suffer from stress or depression in the workplace, because those issues are as material to the lives of people in Scotland, in a real way, as are waiting times. We say that we are concerned—certainly, I am concerned—about people who have to wait too long for an operation, but I am as concerned about people who are off work for a year and a half because of chronic depression. Such issues are as important as waiting times.

Could you recommend any specific steps to the committee, given our short discussion today and your expertise in the field? What should we be saying to the Scottish Executive to make the budget process much clearer and better at targeting specific areas?

I return to the point that we just discussed. The introduction of a high-quality performance management system that ties finance to health and health care outcomes and a transparent system of accountability for both local authorities and health boards would be a real advance.

Thank you for your contribution this morning, Professor Hanlon. I am sure that committee members found it interesting.

I welcome the witnesses from the Scottish Association of Health Councils. We have received your short report, but do you wish to add anything?

Thank you for the invitation to participate in this debate; I welcome the opportunity to do so.

I want to highlight some of the issues that we identified in our submission. We welcome the improvements that have been made to the accessibility of the information in the light of previous statements that we made to the committee—thank you. We also acknowledge and welcome the overall above-inflation funding across all health board areas. However, we have some concerns that the announced levels of increase may lead to some false expectations of what we will be able to achieve; pay awards and other cost pressures may impact on the process.

We welcome the opportunity that the Arbuthnott formula will give to provide equitable funding across Scotland. However, in the light of previous implementation processes, we are keen to see a tight timetable for implementation. We acknowledge the good winter planning that took place, but we point to the increase in emergency admissions, which places intense pressure on acute beds. The impact on waiting times is a matter for concern, particularly in relation to some of the diagnostic assessments in cancer care, which can be a matter of life or death for individuals.

We ask the committee to note our comments about hospital-acquired infections and our concerns about targeting cleaning services for efficiency savings. We would like the committee to consider training across the board for both nursing and cleaning staff to try to improve the situation.

We welcome the clinical governance steps in the Scottish Ambulance Service. We also welcome the additional funding for the state hospital at Carstairs, although there is grave concern about medium-security facilities at local level. That issue has been raised in the past.

In the light of some of your discussions with Professor Hanlon, I want to raise the issue of moving towards a more integrated service. I have great aspirations that the health plan will achieve steps towards that goal. We need to learn from history and move away from situations where expensive equipment was put into local areas without the infrastructure—staffing and running costs—to support it.

You referred to the implementation of the Arbuthnott report, for which, clearly, there is a specific time scale. However, towards the end of last year, health boards received initial moneys and we have reports from all over Scotland that such moneys have not been used to address rurality and deprivation. I will use the example of Ayrshire and Arran Health Board, which did not use that money in the form in which it was intended. That health board is not alone. Do you think that that situation will continue over the five years or will communities in rural and deprived areas see their health improve over the piece?

That relates to performance management, which has been under discussion. Perhaps one of my colleagues can comment on that.

The money has been allocated to certain areas in recognition of the extra costs that are incurred in rural and deprived areas. It is important that that money be spent to tackle the problems that arise in communities as a result of deprivation or rurality. We are aware of the cost pressures on the health service and there is a fear that money might be shifted to help meet the costs—overspends or underallocations, depending on how you want to look at it—of acute services. That is a serious concern. It is important that health boards ensure that the money reaches those areas for which it was intended. It is important that that process is performance managed and that health councils and other bodies are involved in that performance management.

It was helpful that Mr Crawford talked about the involvement of health councils. What are the witnesses' views of consultation with the general public about the health plan and how budgets are set for individual health boards areas?

From my position as convener of the Scottish Association of Health Councils, I have links through the health councils to individual communities in Scotland. We need to build on that, as it is a great strength. We do not want to lose the contact that we have with the people.

The general issue of public involvement is a major item on the Health and Community Care Committee's agenda, as it is for the association. We need to work at how we develop the links that we have made. We cannot assume that because we have made those links, things will happen. We will not always be on top of things and will not always ask the right questions. We need to continue to develop the strategies and to look at the issue from a number of different angles.

Should that be part of the performance management review of health boards and trusts?

Yes. The Government's clear priority is, in a sense, one of giving the NHS back to the people. It is crucial that we have the ability to influence what happens at NHS board level. We must continue to do that through the involvement of health councils. Part of that process is to give those councils the right to comment at every point down the line. In the past, we have had a variable reaction to public involvement across the country. We need to have something at the performance management level so that we can take things forward equitably across the country.

Your submission mentions comparisons between the figures in "Investing in You" and the 2002-03 budget. Will you elaborate on how the budget compares with "Investing in You"?

The document refers to the past two years' figures. As Andrew Gardiner said in his introduction, the information is more detailed and accessible than it was last year. At a meeting that was held at the same time last year, virtually to the day, our organisation criticised the previous year's figures, saying that much of the data had been aggregated into quite broad bands. We welcome the detail in this year's figures. That has led to greater transparency.

We have picked up some specific points that would make the information further accessible. The second paragraph in our submission highlights that. The explanatory notes to a table are spread over 20 pages, which means that people can very quickly lose sense of what is being referred to. We welcome the improvement in the level of detail that is available this year.

Will you give us advice on how public consultation could be fed into the Scottish budget and is there any recognised good practice in that field? After you have kindly answered that question, perhaps you could comment on the disability-proofing of budgets.

I think everyone would agree that the health service has not traditionally been good at consultation. We should welcome the fact that the health plan sets out the requirement for health boards to account for how they will consult people. We look forward to the publication, later this year, of the document that will give advice on consultation. As that document is about how to consult, I hope that consultation will be built into its production. That would seem to be a reasonable first step and a good example to set. The document has been long awaited and we look forward to it with interest.

The health improvement plan and budget documents are not issues that galvanise populations. People do not find them interesting or easy to discuss. The reality is that many of the things that find their way into the plans have been the subject of detailed discussion at the local level. People should not, therefore, be surprised at changes that are made in patterns of expenditure. A lot of discussion has taken place with stakeholders at the local level, including discussion of maternity strategies and a whole range of services including mental health services.

The association recently conducted a survey to ask health councils about good practice in consulting on such matters. Pages 3 and 4 of our document, on priority setting, refer to that. Although much discussion about individual strategies informs the overall plan, health board officers often decide the overall plan and its relative priorities. Dumfries and Galloway Health Board, Argyll and Clyde Health Board and Shetland Health Board have practices that are fairly good examples of how things could be done and improved. There are lessons to be learned.

The Scottish budget does not seem to be disability-proofed—should it be in future? For example, it is generally agreed that communication throughout the health service is severely disadvantaged in attempts to communicate with the deaf, because there is not enough visual communication or deaf awareness.

We need to move with the times and take on board the wider disability issues. We have done that more in recent years. We need to continue to work with experts to ensure that the needs of all disabled people are included in the NHS's spending plans.

I am from Highland and I work locally with several groups. Links with the local community care forum enable us to put such issues on the agenda. In other ways, the development of the voluntary health network is important and we must continue to tap into that expertise. We must look for advocates who will give the picture of what impacts on people. We must use the communication skills that many people have. There may be only 16 registered interpreters, but many other people have the ability to communicate with deaf people. We must listen to those people and use their expertise.

Should a health board budget contain a heading for disability-proofing? Should a sum of money be set aside for that, or is there another effective way of helping?

We must be careful not to create structures that do not deliver. We could go as far as appointing, in each health board area, an individual with expertise, but I am not sure whether that would deliver the necessary breadth of knowledge and information to make informed decisions. We must look at the big picture and try to obtain information locally to reflect a range of disabilities, not just deafness, blindness or multiple sclerosis. We should put everything into the pot and make progress. We have been getting better at that, but we must still work at it.

I wonder whether I could ask the witnesses to write to us on a couple of issues, so as not to take up too much time now. Item 8 in the SAHC's submission says:

"We are concerned at the revenue consequences for Trusts of … the capital charges associated with capital investment projects."

I do not particularly want to go into that huge issue. Perhaps you could write to us about your concerns in a little more detail, particularly if the issue relates to resource accounting and budgeting and the 6 per cent capital charges that half a dozen trusts failed to meet in the most recent audit. Does the issue relate to depreciation or public-private partnerships? I would like some amplification on that.

Amplification of paragraph 18 in the submission would also be helpful. It says:

"There is concern that cleaning services have been targeted for efficiency savings."

In light of the Audit Commission's report on cleaning and the recent study published by the North Glasgow University Hospitals NHS Trust showing that measures can be taken to halve the rate of hospital infection, can you come back to us with some specific evidence of the targeting of efficiency savings? I think that we share your concerns.

My general question is on the presentation of the budget, which you spoke about. It seems to us that things have moved on but there is a problem about identifying what might be termed new money, particularly for investment in bringing staff up to the right level. Item 5 mentions the "new deal" for junior doctors, consultants' intensity payments and above inflation pay awards for staff. Those items are part of appropriate investment in staff, but take a big tranche of any increase.

Do you want a further change in the way the budget is presented to try to split off the money that is required for such things—which are an annual element—from new developments in, for example, cancer, mental health or cardiovascular disease so that we see what money is allocated in the budget as new money? I think that there is a desire in the committee to go more down that line, but I would be very interested to hear your views.

Such a change would be very useful. We are concerned about not knowing what proportion of the additional money is in effect already allocated to additional staff costs. The model that you describe would be welcomed.

I do not know if that would be feasible, but we can at least ask for it.

It would be helpful to have a national picture because each of us is made aware of what is in each of our health board areas. It would be helpful to find out if the local story is actually true.

Paragraph 10 says that table 4.3 in last year's "Investing in You" report estimated an average increase in expenditure of 10 per cent. I will not go through all the figures, but table 5.3 in "The Scottish Budget: Annual Expenditure Report of the Scottish Executive" estimates, according to paragraph 10, an average increase of 21 per cent. Are you saying that there is some misleading information in the document?

There did not seem to be an adequate explanation. The figures are actually 0.1 per cent and 0.21 per cent respectively rather than 10 per cent and 21 per cent. That is important.

The figures are still double.

Having said that, 0.1 per cent of the overall budget is still a large sum. I was seeking an explanation, which is not available here, I guess. I was not sure about the likely explanations of the different method of accounting or the new research that has led to the figures. However, I think that some explanation as to why there is such a big change in the figures between the estimates from two consecutive years will certainly be sought.

We will ask our advisers about that later.

I want to come back to the point that the convener made. Given that Andrew Gardiner is based in the Highlands, I would like to direct it at him. The Highlands did very well out of the Arbuthnott formula, mainly because of rurality. We are looking at how that money is directed towards inequality, access, deprivation and rurality. When I ask questions of the Highland Health Board and the trusts, they say that any money that is spent on any health services will benefit everyone. It will benefit all the areas that I mentioned. What is your health council looking for? How should the money be allocated to address those issues?

We need to look in particular at people for whom the main acute hospital is not really accessible. Most of the spending is in the acute hospital sector and primary care. There is a primary care component, but we need to ensure that the transition between primary and acute care is as good as it can be for individuals in the more rural areas.

I would like more, and more accessible, information to come out of the remote and rural initiative, which is based in the Highlands but covers the more remote areas of Scotland. People working on that could perhaps be charged with doing more research into the question that you have asked about how best the money can be spent to ensure it is spread equitably across the country.

Surely that information is available in certain areas. When we start digging below the surface, we see the disproportionate spend among local health care co-operatives. One LHCC in my area—in the East Ayrshire part of Ayrshire and Arran—sticks out like a sore thumb in terms of deprivation and rurality, yet when we consider the affluent areas such as Alloway, the spend is huge. Does the money go to the wean that cries the loudest? That seems to be the only explanation: if you are articulate in your bid for money, you will get it, but if you are in a remote area and do not have public transport access to where stakeholder conferences are being held, tough luck, you will not get any money.

As Mary Scanlon said, the Arbuthnott funding was for specific purposes. This committee spent a long time on ensuring that we had the indicators right. We hoped that we would be able to trace the funding from the centre right down to the small hamlets in whatever area. The problem that we have found is that the path of the money is blurred once it leaves the centre. Professor Hanlon has spoken about how tracing the money should be part and parcel of performance management. I would like this committee, as well as the health councils, to be involved in that.

That is very important. We are still living with the cycle of deprivation. It has not gone away. In a sense, given the situation that you have just described, convener, when it comes to continuing to feed it, we are still culpable.

The new community health plans will lead to opportunities for tying in local authorities' spending with the health boards. If that is as transparent as we would like, I hope that we will be able to trace where the money is going.

I was concerned when a significant sum of Arbuthnott money went towards paying off the deficit at Raigmore hospital—I think I am right in saying that it was £2.8 million. As the convener has mentioned, there is no money for the LHCCs in the Highlands. Do you share my concern about the doctors in, for example, Helmsdale? People there do not have local access to their doctors, who are being centralised, and petrol is very expensive. Will you keep monitoring the Arbuthnott funding to ensure that it is used to address the issues that it was meant to address?

Yes, we will continue to do that. I share your concerns. A large proportion of that money has been hijacked to deal with overspends from previous years. That is tragic.

Health councils will continue to monitor and try, as far as we can, to keep tabs on what is happening to the Arbuthnott money and to the general pot of money that is available. We can continue to do that only if we have a place at the table. I think that that will come with NHS boards at local level. I think that we will be there and that we will continue to ask questions.

If you respond to Richard Simpson's point about hospital-acquired infections and the role of the cleaning services, would you comment on whether the competitive tendering of such services has had an impact? Have you any views on the centralisation of laundry services in a limited number of locations in Scotland? Has the consequent transport of laundry around the country contributed to the problem?

I have just two brief questions, the first of which concerns ordinary people's involvement in holding health boards to account. I was privileged to be present when the Audit Committee held Tayside Health Board and the two trusts to account at a meeting in Dundee. Although the meeting was very effective, it was necessarily a one-off; no parliamentary committee can simply travel throughout the country doing a similar thing. Is there room for a local mechanism, perhaps in the style of a select committee, which would be made up of local health council members, councillors and staff members and which would meet annually to hold unified health boards to account for the way they spend their money?

I welcome that suggestion.

In answer to an earlier question that we might have missed, the important point about hospital-acquired infections is that we should not under-resource the cleaning services. I do not have any specific comments about the implications of transporting laundry across the country or whether it poses any additional risk. I mentioned training earlier. There should be training not just for cleaning staff but for medical nursing staff on the wards, because some of the stories about people moving from patient to patient without taking the necessary hygiene precautions beggar belief.

As members are aware, the health council's role is under review. As for local mechanisms, I hope that we will be able to engage with that issue in future. Returning to budgets, I should point out that serious public involvement is expensive. My health council's current total spend is less than 1 per cent of the total health spend in Ayrshire and Arran. I am sure that the same is true for health councils in the rest of Scotland. Serious public involvement requires serious money.

Do you think that it is healthy for health board chairmen to appoint health council members?

No, not particularly.

Do you want that to be changed?

Yes.

Who should appoint health council members? Should they be elected instead?

There is no other way round the matter. If we want to be accountable to the community—the people we serve—there should be local elections.

That is interesting.

I thank the witnesses for their evidence and their answers to our questions. We will write to you asking for further evidence on Richard Simpson's points. From some of your comments, it seems that we require to take further evidence from particular individuals about performance management.

Meeting adjourned.

On resuming—