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Agenda item 7 is the budget process at stage 2. I welcome Philippa Bonella, who is ASH Scotland's director of information and communications; Theresa Fyffe, who is the Royal College of Nursing Scotland's director; John Gallacher, who is a regional organiser for Unison Scotland; and Andrew Lamb, who is the British Dental Association Scotland's national director. Thank you for attending the meeting.
One issue in our papers that attracted my concern was the budget line for the workforce. You may or may not know that the draft budget suggests reducing that. What does Unison think about that? The Royal College of Nursing will be pleased, because the budget for nursing is to increase, but I am concerned that reducing the general workforce budget might have an impact on a wide range of non-nurses.
The question is simple but the answer is complex. Unison is a big nursing union as well as a representative of all occupations in the health service. It is right that the question focuses attention on health boards' budgets. As members know, 70 per cent of boards' budgets is for the workforce. Boards are under extreme pressures to meet efficiencies and to deal with rising cost pressures for utilities, which we all know about.
What is the KSF?
It is the knowledge and skills framework. That system has been introduced to ensure proper investment in training and development for all occupations in the health service. It needs to be funded and the concern is felt that that funding might come under pressure because of core service delivery issues.
Workforce projections are influenced by financial constraints. We are concerned about the projected 0 per cent growth in the workforce budget from boards, which relates to financial affordability. As boards go through service redesign, we are concerned that how the 2 per cent efficiencies that must be made are put back into the service is transparent and that how they support workforce growth is clear.
Where could savings be made in our health budget? When I read the papers the other night, my attention was attracted by the distinction awards. Is the health service's entire workforce eligible for those awards? They cost about £26 million. Could we make savings there, which could be reinvested elsewhere in the health service?
If only the bonus scheme applied to all workers in the health service—I fear that it is the domain of doctors and consultants. I leave it to the British Medical Association to speak on their behalf. The scheme is based on agreements that are in place. I do not know the details of those agreements, but I am sure that other associations could speak about them.
We have made it clear that it is interesting that £28 million is being provided for the distinction awards, which will increase by £2 million in the following year, when we are not sure whether, if a pay negotiation took place, any money would be found to support a pay change for others. If that scheme were complementary for one professional group when it was not clear that we could pay for the wider workforce, that would be a major concern. I will not go into whether the arrangement is appropriate or right. The question is more about the balance of funding.
I have a general question about whether you have suggestions—
Ian McKee has a supplementary question on the narrow point.
I had a supplementary question, but I see that Mr Lamb wishes to speak. I note that distinction awards are for dentists, too.
They are, of course, and they are there to recognise excellence within the health service. If that budget were to be reduced, there would be a risk of consultants' moving more into the private sector.
Thank you. That is helpful.
My point is the general one that, as politicians, we are constantly reminded that if we are going to increase one aspect of the budget, we must also suggest where savings can be made. Where do you suggest that savings can be made so that money can be redeployed?
One of the areas that might be looked at—I do not have enough data to go further—is drug efficiency and the use of prescriptions. Although work continues on that, I believe that more efficiencies and savings could be made in that area.
Can you expand on that, please?
Work is being done on what drugs are used and to improve prescription practice. There is a definite change in practice for all professionals, not just in nursing, in being clear about what we prescribe. The issue is probably more about the allocation to the boards, but I believe that, if the directive came, they could do more to make savings in that area.
I agree with Theresa Fyffe. Obviously, we would prefer non-workforce issues to be considered first. As I said before, the procurement strategy for supplies and so on has realised millions of pounds of savings in the past few years and will continue to do so. That is a particularly Scottish strategy that is delivering.
Mr Gallacher, when you say that you do not know whether that has fed through to GP practices, you do not know the effect that that has on our two medical practitioners. There are some mild explosions going off.
I am sure that they will keep taking the medication. [Laughter.]
I am quite disappointed that, out of 10 sets of witnesses who were invited to give evidence, only four were brave enough to turn up. I am disappointed that the others did not turn up because I would like to ask the British Medical Association and others why the distinction awards are going up by £2 million every year.
I should say that some of the organisations that we invited to give evidence have not been able to do so for practical reasons.
Nevertheless, I would like to know the Scottish Association for Mental Health's response to the fact that its budget is standing still, and I would like to ask Capability Scotland and Carers Scotland about the wheelchair strategy. I simply put on record the fact that I am disappointed that six out of 10 of those organisations are giving written evidence and are unable to turn up, for whatever reason.
You are probably aware that, in our response in 2003 to "Modernising NHS Dental Services in Scotland", we felt that the GDS budget should be somewhere in the region of £521 million. In our manifesto for the 2007 election, we revised that figure to £571 million, and in next year's terms it is something of the order of £600 million. Therefore, the budget of £355.5 million is not in itself sufficient to deliver the access that many members of the public and MSPs wish.
Could we get some written information about what could be provided for £600 million and why the British Dental Association thinks that that amount is necessary? In Moray, for example, 15 per cent of adults are registered with an NHS dentist, so the fact that we have received evidence that the situation is getting worse instead of better and that dentists are funded for 55 per cent of their activity is a serious matter.
Yes, and it was a comprehensive response.
We would be happy to supply the evidence for which Mary Scanlon asks.
If you send it to me as convener, it will be sent to the rest of the committee.
The British Dental Association is comparing a plan from more than a year ago with the £355 million plan for the current year and has worked out that £600 million is necessary. How much does the association believe is being funded this year?
We have been asking the Scottish Government for those figures for some time. We have been looking for its spend on the salaried and on the non-salaried GDS, but we have not yet had the figures.
We are aware that the way in which the budget is presented means that the budget lines for GDS, general medical services and, I think, pharmaceutical services are flatlined because the negotiations have not been completed. What disappoints me is that there is no distinction between whatever negotiations go on and the need to increase dental services. Those two aspects of the budget should have been separated and we should be careful not to conflate the two issues. The budget for such services is always presented as a Flat line. The only exception this year is the general ophthalmic services, because a three-year settlement has been negotiated and, therefore, we know the outcome. The question that Mary Scanlon asked and which was suggested by my colleague Ross Finnie, is what increase have you been expecting in the budgets for the totality of services, as opposed to your negotiations for individual contracts?
The reason for the flatline funding is that the Scottish Government health directorate waits until the outcome of the Review Body on Doctors' and Dentists' Remuneration. We are looking for the inflationary rise that the review body gives to doctors and dentists. We would like an increase in the fees, on which we hope we will be able to have a dialogue with the Scottish Government. There has been investment in infrastructure support, which we are pleased about. However, the real negotiations are not those that go on between the British Dental Association Scotland and the Scottish Government health directorate, but our representations to the doctors and dentists review body. I am afraid that those representations bear little resemblance to our belief that we require a substantial increase in funding. Those discussions have to go on in Scotland.
To be clear, are you saying that the only way in which we can increase our dental services is to increase the fees? Should we not put more money into salaried dentists and community services to pull back the effective privatisation of dental services that went on for so long?
The British Dental Association represents dentists whether they are high street dentists or independent contractors and non-salaried dentists or salaried general dental practitioners in the health service funded by health boards. There is not always a like-for-like comparison. The evidence from the workforce review shows that the salaried dental service sees only about 40 per cent of the patients that are seen by high street dentists. That is not because the salaried dental practitioners are not efficient, but because they see a different cohort of patients. The most effective way in which to provide NHS dental services for the people who require them on the high street, close to where they live, is through independent contractors. We are looking for an increase in the level of funding for those dentists to the same level that is provided for the salaried service.
Andrew Lamb has not answered my question about how spending is linked to outcomes. I seek clarification on that.
People are interested in outcomes and outcome targets. There is no doubt that the childsmile initiative in Scotland has delivered an improvement in the oral health of some children. The problem is that the bulk of tooth decay in children is restricted to those who live in more deprived areas. Most tooth decay is in the Scottish index of multiple deprivation's six and seven group. We must attract those patients to attend dentists regularly. The childsmile programme is beginning to make inroads into that. When children are introduced to oral health in nursery or primary school, the parents are encouraged to take them to see an NHS dentist. That seems to be working to an extent. The level of tooth decay is improving for children in more affluent families, but not in those from more deprived areas.
I am sure that it is listening. Under which budget line is the childsmile programme funded?
It comes out of the £355 million for general dental services.
If there are no more questions for Dr Lamb, we can move on to other issues.
I ask the panel to comment on the tobacco control budget.
I am glad that you asked that, because Ms Bonella has not yet had a chance to comment.
I thought the same thing.
Dr Simpson is being charming and a gentleman, as usual.
The first thing to say about the tobacco control budget is that it is flatlined over three years. Although £13.8 million is the most that we have had on tobacco control—on a three-year basis, it is the most money that tobacco control has ever had—we are concerned that, moving into year 2 and looking forward to year 3, there will be an impact on services. According to NHS Health Scotland, tobacco costs the economy £837 million every year, but we are spending only £13.8 million. There seems to be a bit of an imbalance between cost and spending.
What will the pharmacy scheme do?
Community pharmacists will give smoking cessation advice to people in the pharmacy.
Over the counter.
Yes.
We are also disappointed by the lack of increase in funding for tobacco control. Oral cancer is a big issue in Scotland; I am afraid that Scotland suffers a disproportionate number of the United Kingdom's oral cancer cases. There is no doubt that the main risk factors are heavy consumption of alcohol and tobacco, so we are pleased to see the increase in the budget for alcohol misuse, but we are disappointed by the real-terms decrease in the tobacco control budget. BDA members see the effects of tobacco at first hand in gum disease and oral cancer. In December, ASH Scotland, NHS Health Scotland, the BDA and the Scottish Government are holding a conference for dentists and members of the dental team to see how they can link into the smoking cessation schemes. Given that initiative, we are disappointed that there is a decrease in funding for tobacco control.
That is helpful, because I do not think that many people would make the connection between the role of dentists and smoking and alcohol.
I understand that, as well as the £13.8 million for tobacco control, £3 million is going into the community pharmacy scheme. How much is going into work with young people?
There is £2.8 million for work with young people, but it is included in the £13.8 million.
But there is an extra £3 million on top of the £13.8 million.
Yes.
So, the money spent on tobacco control is not going down. It is going up; it is just under different headings. Is that right?
Yes, to a degree. A new scheme has been set up for pharmacies that is not connected with the existing smoking cessation services.
I understand that, but Andrew Lamb's concern at the amount of money that the Government is spending on helping people to stop smoking might well not be justified, given what you said, because more money is going to help people stop smoking; it is just going under two headings instead of one. Is that correct?
That is correct, but we think that more money could be spent on smoking cessation. It is also a matter of making the services sustainable in the long term. Health board services that have been up and running for a few years have flatline budgets and additional money is going to pharmacies under a different scheme. The issue is sustainability.
But the total amount of money that is being made available is going up.
Yes.
For guidance, what is the general profile of the number of persons who smoke? What is the movement in that respect? I am sorry; I should have looked that up before I came to the meeting.
The numbers are dropping, and there are targets in the Government's national outcomes and indicators to reduce the numbers even further. The situation is changing over time, but we think that it could change much more quickly if more money were invested in prevention and cessation work. Around a quarter of all adults smoke now, but the numbers have reduced significantly over time.
So the amount that is being spent per smoker has gone up.
That is probably true.
So you are telling us that we cannot look at only one budget line; rather, we must look at many other lines to find out what is happening. At the moment, even you do not know what will come out of the other pots.
No.
That is an important point. We are not clear about what the smoking cessation budgets are. We need and should have clarity on that. We are talking about what is still the most important public health challenge in Scotland, and we need clarity. The message that I take from the discussion is that the new money is welcome, but we will not be taking the matter as seriously as we should be unless there are sustainable services that respect staff and programmes.
The papers in front of us—
Helen Eadie has jumped the queue. I am losing track. Mary Scanlon was going to ask a question, but I will let Helen Eadie come in.
On that point—
Ms Baillie can see that I rule with a very light touch and that things are done by consent.
In real terms, the money for pharmaceutical services is minus £4.2 million, and there is minus £9.8 million for general dental services. It is a bit like smoke and mirrors. We are saying that there is new money, but the bottom line is minus around £14 million. In fact, in real terms, the money in the overall health budget is minus £16 million, the bulk of which seems to be coming out of pharmaceutical services and general dental services at a time when there are major problems in dental services throughout Scotland.
I hear what you are saying. In fairness, we must let Ms Fyffe say something. She has been very patient.
We entirely agree with ASH Scotland on the sustainability of services. Roles have been developed to deliver that, and they should continue.
Thank you. We shall carefully consider that matter.
My questions are more general; they are not about drugs, alcohol or tobacco.
I suggest that we find out whether the witnesses have any other general comments on the section on drugs, alcohol and tobacco. We can then move on to deal with other matters. I am sorry, convener; that is simply a suggestion.
That is all right. Forbearance is my watchword today.
On a point of information, both the alcohol and drugs lines are in the justice budget.
Thank you. That is helpful.
I have three questions.
Before you go on Mary, it would be helpful if you could tell us what page you are referring to.
It is the HEAT target.
No, I meant what page in the draft budget.
Do you mean the NHS absence rate?
Yes.
It is the Government's HEAT target in "Better Health, Better Care".
I beg your pardon.
It is on page 26 of the briefing paper.
That was my first question. The second one is about single outcome agreements. I am concerned that they are difficult to monitor. Does Unison have any concerns or advice about how we should monitor local authority health spending?
Mary, I do not want to stop you asking questions, but can we deal with the first one first, and then the second? The first question is about NHS boards achieving a sickness absence rate of 4 per cent from 31 March. Can the witnesses address that first, so that we do not get confused?
The 4 per cent attendance target is relatively arbitrary, and the unions do not agree with how it was conceived. The situation is being monitored through the annual accountability reviews. Several health boards are struggling to meet the target within the timescale, but a lot of work is going on with local trade unions to put in place schemes to address health issues among the workforce. Obviously, the workforce is huge and some of the issues that we mentioned earlier, to do with drugs, alcohol and tobacco for example, apply equally to the workforce. We need to make sure that services are available to the workers.
I agree with much of what John Gallacher said, so I will not go over that issue again.
That was very helpful.
Can Unison help with my question about single outcome agreements?
Not in two minutes, no. The question is complex. The joint future agenda was about encouraging health boards and local authority social work departments to pool their resources and money and to have common objectives and service outcomes. That is still at an embryonic stage—the approach does not exist yet.
We welcome local authorities' growing responsibility for health care, which is in line with the shifting the balance of care work stream. However, we have a concern. The committee should consider how a monitoring plan can be established. The outcome agreements can be measured, but we are concerned about the other pots of money that are involved. How are they understood, and how will they be monitored to assess whether they are delivering? We need to be vigilant about that.
What are those other pots of money?
An example is the fairer Scotland fund, which was launched in 2008. Under that fund, £145 million will be provided each year until 2010-11. We want to see how that ring-fenced pot of money makes a difference and what it will mean when it is rolled up.
I have a supplementary question for John Gallacher. I appreciate what he said and I agree that the matter is complicated. We are in a new position, of course, because the abolition of ring fencing has taken us into a different era. When will the committee be in a position to consider the single outcome agreements and monitor local authorities' health spending and the outcomes? Do you have a date for that?
How long is a piece of string? I am sorry, but I do not have the expertise to gaze into a crystal ball on that.
That is helpful. My final little—
Mary—
I asked—
Well, no one else has indicated that they want to ask a supplementary question, so you can go ahead. [Interruption.] Now that I have said that, Richard Simpson and Helen Eadie want to come in. Whenever I say, "That concludes the evidence for today", I see the hands go up.
My final question is a small one for Andrew Lamb. You said that the target for 80 per cent of three to five-year-olds to be registered with an NHS dentist by 2010-11 is not ambitious enough. What would be an appropriately ambitious target for dental provision in Scotland?
An ambitious target would be 100 per cent, of course, but that is unlikely to be achieved. I would think that somewhere between 85 and 90 per cent—
I meant for the whole population, not just for three to five-year-olds.
For the whole population, a reasonable target would be 75 to 80 per cent.
That is for registration with an NHS dentist.
Yes. That would be an ambitious target for the Government. However, if it set such a target, it would have to provide the funding to deliver on it. That is the issue—if the Government is going to set targets, it must take them seriously and provide appropriate funding so that they can be met.
The funding that was transferred from health boards to local authorities no longer appears in the budget. I think that Mary Scanlon was trying to get at how we monitor that spend. We have to accept that the Government made the decision not to ring fence the money, but how do we monitor the spend? For example, I completed a freedom of information request on the choose life budgets for the suicide programme, which were previously ring fenced, and four of the 23 responses showed a reduction in those budgets. What method should we propose to the Government so that we can continue to monitor the funds that have been lost to the health service's control—albeit that they are not completely lost?
That is a difficult question. We need a system that will hold the deliverers to account for the outcomes, based on the general money that has been allocated to them. Ring fencing money from the centre to pump-prime services is a good thing, but the real pressures arise in sustaining local services. Although the health budget will increase by 1.4 per cent, health boards will receive only 0.5 per cent per annum, so in order to meet their base spending requirements and sustain services they will need to make efficiencies from other initiatives.
Do you concede that the difficulties that we face with regard to budget lines are a result of the new way of interworking and that we will be able to determine whether it has worked only a year or two down the road?
Absolutely. Joined-up allocation of budgets and joined-up monitoring of how they are used are needed. The committee process is helpful in making the budget-setting process transparent and open to representations. In health boards, there is a good system for monitoring how budgets are spent, because we get regular reports and input through area partnership forums. There are different systems in local authorities, but at the coalface we are able to monitor how moneys are being spent. When setting budgets, you must ensure that everything joins up.
I can give a small example of how money is moving from health to local government. The budget line for enforcing the smoke-free law now sits in the local government general grant. Recently we analysed all the single outcome agreements, focusing on tobacco. We were surprised to find that only one local authority mentioned in its single outcome agreement environmental health officers enforcing the smoke-free law, despite the fact that they have funding as part of the block to continue to do that. In addition, very few local authorities mentioned youth smoking prevention, despite the fact that they have just received new money for that.
It is fair to say that they do not all put things down in the same way. We must assume that even local authorities that do not mention enforcement of the smoke-free law have charged environmental health officers with doing that. However, I take your point.
The shifting the balance of care delivery group may give you some answers. The group is trying to find a model for joined-up working and resource shift. As a member of the group, I know that the framework that it is using to assess what will happen in community planning may provide some answers. We are trying to understand how we will get a true picture of health provision when we start to make the change. We welcome that change, but we need to know what action will be delivered and where.
You have dealt with the supplementary that I planned to ask. Your comments have been extremely helpful and have clarified a number of key issues and principles that the committee may want to address in its report.
He has to say that.
Nevertheless, the situation is worrying. On the workforce planning part of the budget, although the nursing budget is increasing, have we got the numbers right? Have we got the funding right for new people coming through? Are we investing in health visitors, which we do not appear to have done for a number of years, or is there a planning blight in that area? What is happening in that area and is the budget addressing it?
Data sets on the community nursing workforce are being built. The information is not substantial, and the workforce projections are therefore based on the data that we have, which tend to be based on hospitals and other services. I would not say that the projections that are based on workforce data will necessarily meet community planning needs. We have raised that issue on a number of levels in the past week or so.
Unison subsumed the Scottish Health Visitors Association when we were formed. We have expressed huge concerns about the review of nursing in the community. Richard Simpson mentioned some of our concerns, such as the lack of uniformity across Scotland and the fact that health boards are going in different directions. We are concerned that occupations and disciplines such as those of the health visitor, the school nurse and the community nurse will be diluted and lost as a result of the review. We will continue to express our reservations.
That was helpful.
I have been told that, because of the change in demographics in NHS Borders, there is an imbalance between the requirement for district nurses and the requirement for health visitors. Is that part of the issue? I agree that those staff have different expertise and skills, but sometimes they fit the requirements of the community. That is what was suggested to me in my area.
There is a difference. The principles that we are working on are that local boards will have to find a model or a template that works for them, but that there must be a core component. We do not have a set view about what that is, but we want something so that people can say, "That is the core." An important consideration is what we need to do differently because of demographic changes or needs assessment. Similar comments to those that have been made to you in the Borders are being made in other areas. I have been going around Scotland talking to people a lot in the past few months and I can see that such changes can be radical for them.
Helen Eadie has one more question. Is this your final question?
I have two questions.
If you were Alex Neil, you would have said, "I have one question, but it is in two parts."
This feels like "Who Wants to be a Millionaire?"
Do you want to phone a friend?
I swoon.
Under the concordat that was signed on 14 November 2007, local authorities will for the first time be allowed to retain all their efficiency savings for redeployment to meet on-going or new pressures. What are the panel's thoughts about efficiencies in the health service? Should the health service be allowed to keep its efficiency savings?
My understanding is that health boards are now able to retain their efficiencies for spending locally. However, as I mentioned earlier, central efficiencies targets combined with the need for local efficiencies to balance budgets can put huge pressures on the budgets of health boards, which are the deliverers. For example, the director of finance of Greater Glasgow and Clyde NHS Board said recently that efficiencies have gone so far that it will be difficult to squeeze out more without impacting seriously on workforce issues. Obviously, impacts on the workforce have an impact on services. We are fast reaching the point at which it will become difficult to squeeze out efficiency savings from budget heads other than those for direct services and staff. The next two to three years could be very difficult, both for health boards and local authorities.
You pointed out earlier that one would seek efficiencies from the pharmacy side—from prescriptions, for example—and from commissioning.
Convener, my question is in two parts so—
I hope that this is the second part, not a second question in two parts.
Do not confuse me.
You might want to write to us with a response.
That would be fine.
I will make a couple of brief points. There is a hugely important new duty that no public sector employer has taken seriously enough in service design and employment issues. The duty raises issues particularly for health board and local authority sub-contractors. I will not stray into the whole equal pay debate, but there is a huge financial elephant in the corner. Some might think that the issue is not as huge north of the border because of historic concordats, but the equalities duty is hugely important in service planning, procurement and workforce issues. More attention needs to be given to it.
I have nothing to add to that.
Feel free to write to us about the issue.
We will.
I thank our witnesses and, as usual, I thank committee members.
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