Health and Community Care Committee, 06 Nov 2002

Meeting date: Wednesday, November 6, 2002

Official Report 363KB pdf

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Budget Process 2003-04

Are you quite happy to go straight to questions, minister, or are you in a position to make a statement?

We can go straight to questions.

We want a long question from Nicola Sturgeon, as the minister is eating.

It is rude to speak with your mouth full, Malcolm.

One of the difficulties in scrutinising the budget, particularly the allocation of extra resources, is that we cannot distinguish between baseline expenditure and additional expenditure. Is it possible to provide figures that make that distinction? That would aid us considerably.

Well, if you compare—

Apples and oranges.

The general point is that if you compare this year's budget with last year's budget, you will see the differences in the baseline figures.

Is it possible to break the figures down, in global terms?

There is a general question about how far we are asked to disaggregate and, for the board budget, how far we can disaggregate. That theme has run through all our discussions about the budget in the past three and a half years. For the first half of that period, I was asking the questions.

I understand that we should try to distinguish better between baseline expenditure and additional expenditure. However, the more fundamental point on resources is that that is not an adequate way in which to consider the health budget, because it is not a question of saying, "We do that with the old resources. Here are the new resources and we'll see what we'll do with them." We are trying to do things differently with the whole budget. There are certain problems with separating the figures into baseline expenditure and additional expenditure. That is not to say that we should not try to flag up what the additional money is and what it is being used for, but there are complications in doing so.

I am not quite sure what the end result of that answer was. Is it possible to give more information in the budget than has been given to date?

I have given a concrete example of what you would like that is not contained in the document at the moment.

You could come back on that one, Nicola.

Would the minister care to outline what mechanisms are in place to ensure that NHS boards' expenditure reflects Executive priorities? Is he content that those mechanisms are adequate?

The last time that we discussed the budget, we spent a lot of time talking about the performance assessment framework, which examines the implementation of the Executive's priorities. We said last time that the budget documents were public. I hope that members have managed to see the reports that went out to each board. They contain detailed information about their performance in a range of areas.

That covers how we do things in general, although there is obviously scope to take specific action if particular problems arise in a given board area. Such action was recently exercised. As members will know, we sent some people to Argyll and Clyde NHS Board because issues needed to be addressed there. We are prepared to take such action if we think that there are problems that demand our attention.

So you would say that the mechanisms are satisfactory thus far.

It would be interesting to get the committee's view on that. The question of tension between national decision making and local decision making runs through all our discussions. Even in a given area, there might be tension between the board and a health care co-operative, for instance. There are all sorts of issues around the appropriate level at which decisions should be made, and I am sure that that will run through our discussions today.

Are there areas where we should intervene more and insist that more be controlled from the centre? That is a critical issue in health policy, and we have to be clear about it. What do we have the right and the responsibility to insist on from the centre? What should we leave to local decision making, not necessarily to boards, but perhaps to front-line staff, so that they may have the freedom to innovate and do things differently?

People should think carefully about the balance and the tension between those areas. I think that we have the right to insist on certain priorities. Waiting times are a big priority for us, although that does not always go down well—sometimes it does not go down well even with clinicians. I might have to point out that the desire to reduce waiting times comes from the public, and that we really have to make progress on it. We put a lot of pressure on boards and trusts to ensure that they make progress. We know how difficult that is, but we are putting on pressure to ensure that that priority is delivered.

We have made progress towards ensuring that clinical priorities such as cancer, heart disease and stroke and mental health are high on the agenda of NHS boards. I am not sure whether members have already picked this up in what they have read, but it is relevant to today's discussions: we have reduced the number of different priorities that we give boards for next year. Some members might criticise that, but there comes a point when we have to ask how many priorities we can ask boards to deliver simultaneously. It might be argued that if we have too many priorities, we do not have any priorities at all.

The priorities that we have given boards for their health plans next year are: health improvement; delayed discharges; 48-hour access to primary care; cancer; coronary heart disease and stroke; mental health; health care-acquired infection; waiting times; public involvement; work force development; financial break-even, which is not irrelevant, because if a board does not have money, it cannot do any of those; and, last but probably the most important overarching priority of all, service redesign. Unless boards engage in service redesign, they will probably not deal with many of the problems that they face in relation to waiting, cancer or mental health, for example.

The fact that we have reduced the number of priorities might be useful for the discussion. I suppose that the corollary of that is that we will be even more determined to ensure that the objectives and targets are met in those areas.

What mechanisms exist to measure the clinical effectiveness of health expenditure? How is that reported?

There are different ways of measuring clinical effectiveness. The work of the Clinical Standards Board for Scotland represents a key new development in the lifetime of the Parliament in setting national standards and ascertaining whether those standards are being implemented in the various parts of the health service.

There is a history of clinical audit in Scotland, using guides such as clinical outcome indicators. Indeed, Scotland pioneered the development of many of the indicators, which show whether progress is being made on particular diseases, for example. We are keen to extend clinical audit work and strategies such as the cancer strategy and the recently announced coronary heart disease and stroke strategy.

More clinical audit is crucial for the development of evidence-based best practice. Many different mechanisms are in play, and I am confident that the health service is making great strides. Much of the discussion of the health service is in quantitative terms, which is fair enough as we have to ask how much activity there is and how long people are waiting, but we are also improving the quality of care. Many of the activities and mechanisms did not exist in the past, and I am sure that I have omitted to mention others.

However, the current emphasis is on reducing waiting times. We are putting in funding when we should really be measuring the effectiveness and outcome of the clinical treatment. It would be great if someone was referred today and seen by the specialist next week, but if they did not have a good outcome, it would be meaningless.

There is a vast amount of information about that, and I referred to some of it earlier. It includes clinical indicators and there is an audit of surgical mortality, which at least moves us in the right direction, although there is always room for further improvement. As I said, there is an increasing amount of clinical audit.

I agree with the member entirely. No patient in Scotland would want to have a shorter wait at the expense of the quality of care. Some members will undoubtedly have seen the remarks of Dr Peter Terry, chairman of the Scottish Committee for Hospital Medical Services, in last week's The Sunday Times. He said rightly that consultants' work is divided into three parts: emergency care, which as always has to come first; routine clinical work; and sessions spent on audit. That was a statement of fact, and all parts are important. I am sure that Margaret Jamieson is not drawing the conclusion that waiting is not important. Obviously, it is important to patients, which is why it is important to us, and in some cases, waiting too long can affect the quality of the outcome. For all those reasons, we attach great importance to waiting.

Perhaps Nicola Sturgeon will string her various questions together.

The first one has been dealt with under Bill Butler's question, so I will move on to the next. The budget makes several references to projects such as rolling out NHS 24 throughout the country and funding measures to improve the recruitment and retention of front-line NHS staff. Should not figures be given on the planned expenditure for those projects?

The figures are given for the roll-out of NHS 24, and there is a budget line for NHS Education for Scotland. Some of the budget lines might be at a lower level, because we were asked only to give certain lines in the budget report. It might be possible to give more detailed information. We have had the specific initiative on nurse recruitment and retention, to which we put £5 million this year, so that will be carried forward, although some of it will be contained in different budget lines.

We can certainly consider giving more information. Some of the funding is more generic, and happens through the work of bodies such as NHS Education for Scotland, which covers several different staff groups. The answer to many questions is that a lot of the funding is rolled into boards' budgets. The budgets for continuous professional development are part of board budgets and become part of trust budgets.

This year, we have tried to boost some of those budgets by putting £1.5 million into continuous professional development for nurses, for example. However, the bulk of the budget is within the general budget for boards and trusts. That might lead people to ask why we do not simply split up the budgets of boards and trusts and put rings round this or that budget. There is always an interesting argument or discussion to be had about that.

As the draft budget makes clear, any salary increases must be met from health board allocations. The minister will have given thought to the costs of the new consultants contract—if it is implemented—and any increase in nurses pay that may result from the pay review process. Is the minister confident that the proposed allocations will allow health boards to meet those obligations comfortably?

One feature of the fact that health service pay is still agreed at a UK level is that the money for the consultants contract, for the GP contract and for "Agenda for Change" was all part of the UK spending settlement. That was reflected in the English health budget and in the Scottish health budget as well.

Nicola Sturgeon makes a fair point when she says that a lot of the increases will go towards pay. I do not make any apologies for that. The staff in the health service are the health service. The staff are the people who not only deliver and improve the services but who, by and large, lead the changes, so they should be rewarded. A feature of those contracts—those that have been agreed and those that are still being discussed around "Agenda for Change"—is that, yes, there will be extra money, but new ways of working must go with that. That is part of our approach to pay.

I questioned not the merits of the salary increases but the ability of health boards to pay for them.

Lastly, I have a detailed question about the "Draft Budget 2003-04". I know that the document cautions against making direct comparisons between the figures that it contains and those contained in the annual expenditure report, but I was struck by one entry, under "Other Health Services". Is there an easy explanation for the 29 per cent reduction between the figure that was in the annual expenditure report and the one that appears in the draft budget?

John Aldridge will correct me if I am wrong, but I think that the fundamental reason for that is that NHS 24 and the Health Education Board for Scotland have been removed from "Other Health Services" and now have a separate line. I think that that makes up all of the difference.

There were a couple of changes. First, the Health Education Board for Scotland and NHS 24 used to appear under the "Other Health Services" heading, but are now under the heading "Hospital, Community and Family Health Services". The other change is that the money for the National Board for Nursing, Midwifery and Health Visiting for Scotland, which used to appear under "Other Health Services", has also moved, because it has been merged into NHS Education for Scotland.

Are all those things now under "Hospital, Community and Family Health Services"?

Yes. They are all now under that section.

I am sure that all the figures work out when the sums are done, but a 29 per cent reduction in "Other Health Services" and a 4.36 per cent increase in "Hospital, Community and Family Health Services" does not seem to be right.

"Hospital, Community and Family Health Services" is a much bigger budget. I am sure that it comes to the same thing.

I simply ask for an assurance that we have been given a full explanation.

Yes. I have explained it.

How has this year's budget improved public involvement in local and national decision making on health expenditure?

There is a great deal of activity around public involvement in local decision making. I do not have much to add on the involvement of the public at national level in the budget process since my previous appearance before the committee, but I can say that the health department's policy-making process is inclusive and involves a large number of outside interests, as the committee's next agenda item will illustrate.

At local level, a lot of work is going on, as I tried to describe when I last appeared before the committee on 18 September. Following on from our framework document "Patient Focus and Public Involvement", we had a series of initiatives, most of which worked at local level, but some of which were to establish new national structures to support and facilitate public involvement. Obviously, the future of health councils is a key issue. I hope that, before too long, we will have a document about that. A great deal of activity is under way, but much of it is taking place at local level. Boards are being supported to engage better with the local public. The new draft guidance on public involvement in service change, which we discussed last time, is part of that work. The situation is in flux, but I hope that we are moving in the right direction.

I accept that a number of initiatives are on-going and that there are a number of draft documents and draft proposals. However, although the Parliament has now been established for a few years, members of the public frequently say that they do not feel that they have any input into spending decisions. We often tell people how much money we are spending, but it is difficult to track that through the system. Is there any indication of the time scale for making the decision-making process more transparent, so that people feel that they can have an input into it?

There is a local dimension to that issue, as many spending decisions on health are made locally. There is also a national dimension to the issue. Much of the involvement of patients and the public relates to particular service organisation issues. There is increasing patient involvement in decisions about particular disease areas, because of the cancer strategy, the CHD and stroke strategy and the mental health strategy, which we have just discussed. Some of those decisions involve funding decisions. One feature of the cancer strategy is that local cancer advisory groups have made decisions about investment priorities. Patients have been involved in all parts of the cancer strategy.

There are many strands to the issue that Janis Hughes raises. I do not know whether she is asking specifically whether there should be greater public involvement in decisions about the issues that we are discussing now. My response to that question at a national level must relate to the processes that we undertake for the budget as a whole. I would welcome more public involvement in decisions about spending, because it is important that an increasing number of people become aware of the nature of political choices. There is always a danger of people believing that they need only to say that something is desirable in order to have it. Politics is about making choices, which are often spending choices.

We can empower people to accept choices only if we give them full information in the first place.

Janis Hughes is absolutely right. I am committed to having greater transparency. I am aware that members will not be satisfied with the degree of transparency in the health budget. I am not satisfied with it, either. There are inherent difficulties, which we have described previously, that relate mainly to the fact that such a large proportion of the health budget is assigned to NHS boards. That raises an issue that we touched on a moment ago. To what extent should we instruct boards on what they do? To what extent should they make choices and exercise responsibilities at a local level? To what extent should we say, "You will get so many pounds for this and so many pounds for that"? There are inherent difficulties in making the budget more transparent, but that does not mean that we should not try to do so.

Another issue that has arisen frequently and is of concern to the public is postcode prescribing. What progress has been made on tackling that problem?

Progress has been made on that issue. Are you asking about postcode prescribing in the narrow sense—with respect to drugs? Often postcode prescribing covers postcode care.

I am asking about postcode issues in general.

We are faced with a dilemma, because this is the question that we have already discussed in a different form—to what extent should we direct services from the centre? The corollary of directing that more of one service should be offered is that less of another service will be available. We need to decide how much we will insist on and how much local variation we will allow.

I accept that on some matters it is unacceptable to have postcode care. We have sought to deal with that issue through the performance assessment framework, for example, which identifies priorities that we intend to monitor. We believe that the Scottish Parliament and Scottish Executive have a right to insist on those priorities, because of their democratic legitimacy. However, it would be dangerous to take that approach too far.

On postcode prescribing specifically, the Health Technology Board for Scotland comments on the National Institute for Clinical Excellence judgments on particular drugs. We have made it clear that boards should take account of that and make sure that the drugs are available to meet clinical need, if the HTBS has given that recommendation.

That approach has been rolled out in Scotland over the past year. We are saying that NHS boards should be following HTBS advice on drugs and ensuring that those drugs are available to meet clinical need. Again, however, we do not want to interfere with clinical decisions in any way.

I do not think that anyone disagrees with the principle behind the process. The problem is that, at the local level, the advice does not seem to be followed in practices. MSPs' postbags are full of letters from patients who say that, if they lived three doors up, they would be in a different NHS board area and would be able to get a different drug. That is the problem with postcode prescribing. The principle might be right but the right thing is not happening on the ground. What are you doing about that?

The process is working better this year than it was last year but that is not to say that the problem will suddenly disappear. The reality is that the option is not a cost-free one. If a certain drug has to be made available, that will have a cost. Obviously a drug should be made available, but NHS boards still have to make spending allocations to make that happen.

We have made the judgment that we want to do something about postcode prescribing, but we also have to accept that, in the real world, that will cost money. Some drugs are expensive and we obviously have to give NHS boards a little bit of time to find the funding to ensure that those drugs can be delivered.

You have already touched on two of the most important issues in health: pay and drugs. The cost of pay and drugs is an important feature of health budgets. If we decide to spend more on drugs, that will have consequences for other parts of the health budget.

Margaret Jamieson has a supplementary question and then I will come back to John McAllion.

Minister, I appreciate what you have said about health boards having to consider the financial implications of making a new drug available. However, that is not the way in which individual health boards areas are looking at the issue. If NICE makes a recommendation in January and the HTBS considers that advice and makes its recommendation at the end of February or the beginning of March, it will be August before my constituents have an opportunity to receive, or not, the drug. Each organisation is rehashing the same process.

If the HTBS says that drug B provides a better clinical outcome for a specific group of patients, I challenge any health board to say that it has greater expertise than the people who are involved in the HTBS and NICE. However, health boards often rehash the whole procedure. I accept that what you are saying is correct and happens at the top of the chain but, at ground level, it ain't happening. We ask that you consider that and perhaps put another tick box in the performance assessment framework. You knew that I would not miss an opportunity to talk about the PAF.

It is best to proceed example by example. If there are particular problems, we should consider them. However, I do not think that a certain amount of time lag is unacceptable. You might be asking a question about the future of the HTBS with reference to the current issue, but perhaps you are not. The time delay between the HTBS and NICE making their recommendations does not seem to be all that long. However, there might be financial or other reasons for a further time delay.

The people who are sitting on my advisory group are not accountants, but clinicians. They are considering the merits and demerits of new drugs and I do not think that that is the best use of their time. However, that issue might be for another day.

What progress has the Executive made in identifying unmet need in relation to Arbuthnott? The question is similar to the one that Janis Hughes asked about postcode issues. Can the Executive provide evidence to show that health inequalities are being targeted?

A sub-group of the Arbuthnott group is considering the issue. That sub-group, under the chairmanship of Professor Kevin Woods, is looking at the formula on an on-going basis. Its report will come out quite soon. Although I have heard about the report only in general terms, I think that it will be good. The whole issue of unmet need is an important dimension of health inequalities. All committee members understand the issues, but, to put it simply, someone in a more deprived area might be less likely to use services. That should be taken account of in resource allocation. The report is an important piece of work. It demonstrates one way in which we take health inequalities seriously. I hope that there are other illustrations of that.

Another important piece of work, which is also coming to a conclusion, is the development of health inequalities indicators. That is an important part of taking health inequalities seriously. If we do not have indicators, we might just be talking fine principles and aspirations. I will get the important report from that group quite soon.

We have flagged up one aspect of health inequalities in the document "Closing the Opportunity Gap", which was released as part of the budget process. One of the indicators that we flagged up was mortality from coronary heart disease among people under the age of 75. The figures show some shocking inequalities between different social groups. We have said that we will look at that area.

Margaret Jamieson also asked how we ensure that health boards focus on tackling health inequalities. Aspects of the performance assessment framework are focused on that area. The development of indicators will be helpful in that regard. Until we have indicators, progress might be difficult to measure and demonstrate.

Will the ownership of community plans by local authorities make it possible for us to see a move towards the application of a localised Arbuthnott formula?

Are you tempting me to stray into the area of local government finance?

No. The situation is that local authorities are legally in charge of drawing up community plans, but health colleagues are part of the group that is involved in pulling that together. A large amount of the money involved will come not from the local authorities, but from the health budget. Local authorities are in a far better position to identify areas of deprivation or rurality, or areas in which it is insufficient just to have a visiting GP. Authorities might move towards a mini-Arbuthnott formula more quickly than would have been the case if community plans had been left with our colleagues in the NHS boards.

You are talking about the distribution of money within community planning partnerships, rather than our distribution of money to local authorities. I am pleased about that. You are right that local authorities have a lot of experience in that regard, as they do of issues such as social inclusion partnerships. Community planning is a big issue for us in the health area. When we talk further about health improvement strategies, community planning will be an important part of that discussion. A focus on health inequalities has to underpin all our health improvement work. I am sure that the experience of local authorities will be useful in that regard.

I will turn to the issue of the private finance initiative.

You surprise me, John.

The committee has recommended that the Executive should provide and publish all the details that are contained in a contract. You have responded to that recommendation by saying that private companies who enter into those contracts

"should have the right to exclude or delete text from documents if the publication of that text would put their interests at risk or allow competitors access to commercially sensitive information."

Who decides what text is to be deleted from those published documents—the private companies or the Executive?

That issue arose last time I came before the committee. We promised to send a letter. I have with me a letter from John Aldridge, dated 30 May. He indicates that the issue is not necessarily a health department matter. I should let him answer the question, because he wrote the letter.

It is for the private company to decide whether there are matters that are commercially sensitive.

Does the private company decide that or does it consult the Executive?

The situation has never arisen, so I do not know what happens.

A private company has never deleted anything from a published document.

I am not aware of that having happened. The health board that enters into the contract will have a copy of the contract.

I am thinking about the public, rather than the health board.

If any information had to be deleted from a contract for publication purposes, the health board would be aware of that.

The Scottish Executive would not necessarily be aware of any such deletion.

No—there is no particular reason why we should be aware of a deletion, as we do not hold the contracts centrally.

We would have to quiz the NHS trusts that are involved in contracts with private companies to find out whether any information was being withheld.

It is open to anyone to ask the relevant NHS trust or health board for copies of the documents. If concerns exist about the withholding of information, the body concerned can be asked what has been withheld.

The issue is of public interest across Scotland, because PFI is a highly controversial method of investing in the national health service. Should not the Executive publish the information in its budget plans, so that ordinary people can look at those plans and find out how much has been spent on PFI contracts, how much the private sector has put in and how much the health boards are paying? Do we not have a right to access that information?

I do not think that such information would be withheld.

We do not know whether it is. We have heard that the Scottish Executive does not know what information is withheld.

I am happy to explore that issue. Information on annual cost issues is certainly not withheld or hidden away. Some of that information is outlined in the report that we have provided.

The recommendation is that all such information should be in the published budget.

I am not aware that information on any of the issues to which you refer is withheld.

I am not suggesting that such information is withheld. I am asking why all such information is not made available, in detail, in the budget documents that the Scottish Executive publishes. Usually, the only thing that is published is the cost of the PFI contract to the private sector.

I am ready to be corrected, but I believe that all the major PFI contracts are available through the Scottish Parliament information centre.

I am asking why that information is not available in the budget document.

We wrote a longer budget document, but we were told that there was a desirable length and that we could not include everything that we wanted to.

I would not object to the inclusion in the budget document of any amount of detail on PFI contracts. I suspect that the public would not object to that, either. Why do not you do it? Do you have something to hide?

The PFI contracts are available through SPICe. I am sure that you have read them all.

I want them to be accessible, not simply available. It is not right that people have to burrow and do research to find out such information, which is of public interest. PFI contracts are highly controversial and people want to know how much they cost the NHS and how much they cost the private sector. Why do you not publish the information?

We publish the overall figures.

The information is not published in the documents that are made available to the Health and Community Care Committee.

Much of the information is in the documents that you have been provided with.

The PFI contracts are available through SPICe. We have taken up that issue in the past.

The information might be available through SPICe, but why is it not available in the documents?

The main figures relating to PFI and public-private partnership contracts are in the documents.

Until this year, the figures have not been in the documents.

I think that the figures are in them now.

I want to move on. In a way, that question was almost predictable. The next question is utterly predictable.

Will the minister explain the inconsistencies—that is the word that the committee's adviser, Professor Midwinter, uses—between his attitude to increased improvements in neurological services and his attitude to chronic pain services? The minister appears to agree that neurological services are inadequate and to want an improvement—the implication is that he will give the issue a national steer. However, he leaves the pain question to local health boards. Highland NHS Board, for example, has no chronic pain services.

The committee made only two requests. One was that neurological services—particularly those that affect 30,000 epilepsy patients—be improved throughout Scotland and the other was that comprehensive chronic pain services be established throughout Scotland. Why does the minister seem to have let down chronic pain patients so badly?

I am not convinced that there is an inconsistency. That relates to the general point that I made at the beginning. How much will we direct from the centre and how much will we leave it to boards or—more fundamentally—front-line staff to develop and improve services? I have said on the record many times in the past few weeks that we cannot have a command-and-control health service. We will not change the health service by operating in that way.

We must take our responsibilities seriously and ensure that the priorities that we set are delivered on. I read out the 12 priorities that we have set. Dorothy-Grace Elder asks me to add chronic pain to those priorities. Chronic pain services are important. They are different from some other services, because, to put it simply, pain is a symptom, not a disease. However, that is not to say that something should not be done about it. We are active in that area. Mary Mulligan has had several meetings on that recently, including one with the cross-party group on chronic pain. She is involved in developing work on the matter.

We want to examine good practice to find out whether we can facilitate its development and encourage co-operative approaches to care across board boundaries in some cases. I recently read about a managed clinical network for pain services in Tayside, which seems a good way forward.

Tayside is a centre of excellence that is overloaded with patients from other areas. A health board survey showed that patients in pain from Scotland are being sent as far as Liverpool and London and are being shifted up from the Borders to Aberdeen. As Highland has nothing—you again leave the matter to Highland NHS Board, which admits that it has no chronic pain services—Aberdeen, Glasgow and Edinburgh are overloaded with that area's patients.

The situation is scandalous. As you know, more than 500,000 patients are in pain. You talked about giving a steer from the centre—we ask you to do that. The committee appeals to you because we have had a steer from the public. As you know, 130,000 people responded to the pain campaign in the Parliament. The budget says—rightly—that the Executive wants to hear from the public. You are anxious for a public response, to the point of holding roadshows. The public have given us a steer. They have virtually given us our orders—they want their pain treated adequately. I am sorry, but you are not doing that. Will you say something better?

I am partly describing the dilemma. We must ask how much the health department should dictate the range and nature of services throughout Scotland. We must facilitate and support change. I want chronic pain services to be developed, but you are asking me to add chronic pain to the list of priorities.

The committee has asked you to do that.

The issue is important, but that could be said of many other issues, too. I want progress to be made. We must acknowledge that the issue is difficult and is different in the way that I described—it is not a disease, but a symptom of many diseases. Indeed, important progress has been made on issues such as cancer pain. In the past year, there have been many developments in palliative care through managed clinical networks and the extra consultants in that area at the Beatson clinic.

I do not disagree with your desire to develop pain services. However, I would find it helpful if I knew the committee's precise demands. Are you asking me to issue guidance, ring fence money or add the issue to the health plan's list of priorities? I could argue that we are progressing the matter because of the interest that we are taking in the area. We are certainly trying to support, encourage and facilitate the development of those services.

In what way? You are leaving the matter to the boards. The public have already asked you to give them a steer. They do not rely on the boards. After all, pain is not a vague thing; there are centres for it. However, Highland has nothing and other centres are overloaded.

I have made it quite clear that I think that the area is very important. I ask people to think about where they want the balance to be struck in the things that I dictate. Worthy as pain services are, one could produce a list of 20 services that were equally worthy.

Not for an area with a population of 500,000.

There has to be a balance between what we dictate and what the local areas decide that they need. The issue is also partly about developing new models of care. In fact, it would not be right to impose a central model of care for such an area, because different members of the work force have their own important roles to play. For example, we should consider the crucial role of allied health professionals in pain services.

But they need encouragement.

I am certainly happy to encourage, Dorothy-Grace, but I am not clear whether you are asking me to do more and, if so, what more you want me to do.

I should point out that the committee issued a questionnaire. We were disappointed by some of the responses that we received from parts of the country, because they showed that there was a patchy service. However, we should take on board the minister's point that there is probably no one-size-fits-all solution. Highland is one of the areas that does not appear to have any sort of pain service at all; indeed, committee members probably remember taking evidence from Highland Health Board when the matter came up. However, there are particular issues around the needs of rural and remote areas that might make it more difficult to provide certain services there than in other parts of the country.

Minister, we have written to you to raise some of the issues that emerged from the questionnaire. We will take the matter forward when we receive your response and perhaps suggest a set of recommendations that you can accept or not. We are still trying to get to the bottom of information about what services are available and the direction in which the Executive, the boards and the trusts are travelling on the issue. However, you made a valid point when you said that a lot can be done by learning from people who have done the work and by rolling out that best practice into other areas where services may not exist.

I am aware that we have another small agenda item that we should move on to. That probably brings us to the end of our budget questions to the minister.

Minister, I just want to know what I can tell the public and the cross-party group.

Well—

With respect, I have said that there will be a way forward for the committee to finalise its work on the issue when we receive a response from the minister. At that point, Dorothy-Grace, it will be up to the committee to propose specific recommendations that the minister can act on or not, as the case may be. If I may say so, that will be about action, not rhetoric.

With that, I bring the public part of the meeting to a close and thank the minister for attending. However, he is not leaving just yet.

Meeting continued in private until 14:27.