Budget 2001-02
The budget is the final agenda item that involves the minister. Do you want to make an opening statement, minister?
I am happy to go straight to questions.
In that case, I will kick off. One of the issues in the committee's report on the budget was transparency. The question concerns the total budget figure, which confused me when I first saw the comprehensive spending review. Our baseline is the figure for this year in "Investing in You"—£5,416.5 million. In the comprehensive spending review, the figure is £5,587 million. Is that difference a result of resource accounting, or something else? If it is because of resource accounting, I expect that John Aldridge is desperate to explain—briefly—how that impacts on the health budget.
I expect that John is indeed desperate to explain.
It is because of the change to resource accounting. The actual amount of money that is available to the health service to spend has not changed as a result of the change in the figures. The figure that was published in the comprehensive spending review outcome is known as the total managed expenditure figure. That comprises two elements: a departmental expenditure limit, which is broadly similar to the cash figure that was announced earlier, and the figure for what is known as annually managed expenditure, which is a consequence of resource accounting and which represents money or resources that are more subject to fluctuation than those that are included within the departmental expenditure limit.
For example, the UK figures for unemployment benefit and so on come under annually managed expenditure, because they fluctuate, depending on the level of unemployment.
I understand that the Minister for Finance wrote a letter to every MSP in September, explaining the move to resource accounting and budgeting. An annexe was attached to the letter, with a table showing the changes that had been made from the cash figure to arrive at the resource figure, as published in the document.
I refer to "Investing in You" and the definition of one-stop clinics and walk-in-walk-out hospitals. How much do those hospitals cost? Are any at the planning stage?
My other question came up when Mr Aldridge was speaking: given our commitment to public health, is there a means in the budget by which we can see the resources that are being channelled towards the future public health budget?
There is no single definition of a one-stop clinic because different parts of the service in different parts of the country work in different conditions, and they will design their clinics slightly differently. The general principle is that someone can be referred to a clinic in which they can get diagnosis and treatment quickly. There should be people there who specialise in, and are skilled in, the condition in question.
Where the one-stop clinic approach has been developed, there have been dramatic improvements in the overall patient journey, and the approach has enabled diagnosis and treatment to be offered more quickly. We made a commitment at the start of this parliamentary session to double the number of one-stop clinics by 2002. There were 80 such clinics, and I am pleased that we have now met that commitment: more than 160 one-stop clinics are in place across the country. Having seen several of them in operation, I am very pleased about the benefits that patients have derived from them.
With the concept of walk-in-walk-out hospitals, we must recognise that, in the future development and configuration of hospital services, more and more treatment—specifically surgery—can be, and is being, delivered on a day-case basis. Currently, that applies to about 60 per cent of all non-emergency surgery, and that is a consequence of advances in treatment and medicine.
Experience elsewhere provides strong evidence that a better targeted, more effective and more responsive service can be given where emergency and non-emergency surgery are kept separate, as that allows patients to be booked in for certain more routine non-emergency procedures, examples of which would be operations involving hernias and cataracts. Patients undergoing such surgery can be treated and sent home quickly, which makes that treatment different from the much wider range of emergency surgery that is generally provided.
No facility of that nature is currently at the planning stage. A number of parts of the country are considering whether such facilities—often described as ambulatory care and diagnostic units—could be developed. That forms part of a number of local acute services reviews.
As members are aware, the Executive has targeted significant additional resources specifically to public health, notably the £26 million that is the Scottish share of the tobacco tax. A separate issue that will be of interest to the committee is how such targeting of resources is shown in the budget documents. That was one of a number of issues that was raised during last year's budget process and I expect fully that it will be taken on board in future. I also expect that the Scottish health plan, which will be published at the end of November, will give further details of how our investment strategy for the next few years will be linked to our priorities for public health and to wider reform in the NHS.
The minister will be aware that the committee is keen to develop the health promotion aspect of the public health service. We have spoken to the minister about that in previous discussions. One of our difficulties with the budget was that activity in relation to health promotion was disaggregated. There are central elements, such as the £26 million from tobacco tax, but other elements are contained in health board budgets. To enable us to tackle the matter strategically, we need to have that wider perspective. Will the minister assure us that, to allow the performance of health promotion to be monitored across Scotland, we will be able to get such details in the budget?
We have talked about monitoring and performance measurement today. Those subjects are dear to my heart and we have spent a lot of time working on them in the department. Ultimately, however, I am interested in results. I do not want to spend so long measuring and monitoring, or ensuring that others do so, that we cannot deliver results. I hope that we can strike a balance between those elements in the new performance management framework for the service.
That said, I am supportive of the principle that underlies Irene Oldfather's question, which is the idea that there must be better and more effective co-operation across the country on health promotion among a whole range of areas. It does not make sense for national health promotion activity not to be reinforced effectively at a local level through local health promotion activities.
The work that we have done on the public health agenda has started to address that. The Health Education Board for Scotland has a key role to play, as do a number of local health promotion organisations. We have recently established the public health institute and Phil Hanlon has been appointed as its director. I am keen to continue to improve that area and would welcome comments and feedback from the committee on those points.
I will take up one of the points that the minister made about results, not only in relation to health promotion. We indicated that one of our principal concerns was that information on spending should be transparent, so that the public can enter the debate about how money is spent on health care. When the minister talked about Arbuthnott, she mentioned what she expects to happen and the measures that she is putting in place. I am sure, however, that the minister is aware that MSPs and the general public are concerned that, despite all the announcements in recent years of record levels of expenditure in the health service, they are not seeing results. How long is the minister prepared to give health agencies to produce results and improvements before she takes action?
Hugh Henry's point has been at the core of discussions that have taken place over many months and which will come to fruition with the publication of the Scottish health plan in November. He is right to make the point—I have identified it myself and many people throughout the health service have raised it with me—that although substantial additional investment is going in to the NHS, it does not always reach its target or benefit the patients that it ought to benefit. There are a number of reasons for that, some of which require action at a national level, including the performance management framework and so on that we discussed earlier, and the systems and structures of the NHS in Scotland.
Under a previous Conservative Administration, a range of local NHS bodies was established under the internal market, each of which developed its own decision-making structures and infrastructures. Although we have taken away the contracting mechanisms of the internal market, there is still over-complexity and over-fragmentation in the NHS in Scotland, which all too often militates against not only effective spending, but effective service delivery. That has been at the heart of our discussions on NHS modernisation. We want to get better at measuring and monitoring local health systems, but in doing so I do not want to look only at where health boards are spending the money.
For example, two health boards might each spend an extra £3 million on mental health services, but one might deliver massive improvements while the other makes barely any difference to the services that are provided. Unless health boards spend their money well and effectively and unless they also tackle bureaucracies, demarcations, old working practices, inefficient systems, professional mistrust and poor communication—the list goes on—people will not get the improvements that they need and deserve. I want all those problems to be tackled. In measuring the service more effectively, I want to measure not only where money is spent, but the results that that spending achieves and the standards of service that local health providers deliver to local communities.
"Investing in You" was supposed to be about contacting people directly and involving the public, as Hugh Henry said. On information access for the public and the committee, I wish to take the minister back to one of the more heated and less instructive evidence-taking sessions—the debate on private finance initiatives, during which the committee took evidence from the minister and John Aldridge, the director of finance. There was a contradiction about what information was available. When the minister gave evidence on 10 May, she told the committee that she would give a more detailed submission on the information that was available and where that information could be accessed by the committee and the public. It is now 24 October. Does the minister have any thoughts on that?
I am not aware that there were any contradictions at that meeting between the director of finance and me, but I am sure that if Duncan Hamilton thinks that there were, he will tell me. I regret that the additional information that was requested was not provided sooner. It was submitted to the committee during the past two days.
It was not submitted to the Health and Community Care Committee. I do not know which committee it went to, but it did not come here.
I have seen the paper and signed the letter. The matter was identified when the committee clerk liaised with the health department about any outstanding issues.
We look forward to receiving that submission. Some substantial issues about which there was serious concern are involved. We needed to know—for the full budget process—whether the PFI projects that were being pursued represented value for money and whether public money was being spent appropriately. The minister could give the committee a commitment today—as she has in the letter that we have not seen—that enough information will be provided to allow the committee to make that judgment.
A detailed paper accompanies the letter, which I have signed. I regret that members have not received it sooner, but I hope that it will answer Duncan Hamilton's questions.
Will we able to access information on value for money?
I think that that information is set out in the paper in some detail. If, after members have read the paper, they decide that they want further information, we will be happy to deal with any such request. As part of the internal reorganisation of the department, we have introduced new arrangements for committee liaison and we have been working closely with the committee clerks on that. I hope that such matters will not fall through the net in future.
The messages that the minister gives about quality, performance management and outcomes rather than inputs are extremely welcome. However, a concern that is specifically related to the budget is the way in which level III expenditure is laid out. It does not help very much to have an aggregated amount—£4.3 billion—for health boards. That does not allow members or the public to understand what is going on. MSPs see what is happening at a micro level—such as the recent proposal in Tayside to cut a paediatric epilepsy nurse position, which is of enormous value—and can raise issues with local health boards and so on. What we cannot get to grips with is the process of disaggregation and reaggregation at national level. Will the minister and her department examine the possibility of saying how much is being spent on, for example, mental health issues, cardiovascular care and diabetic care in each health board and then reaggregating those amounts at national level? That would give us information about level IV, which is equally important, and would allow us to benchmark health boards so that MSPs can question them.
For example, we could ask a health board whether it is spending less on diabetes because it is more efficient. It might be argued that a health board does not need to spend so much on diabetes because it is dealing with it more cost-effectively. However, it might be that a health board has not prioritised diabetes, although the Executive has made it a priority. We cannot help the Executive as we would like to, because the budgetary system is archaic.
It is always welcome to hear members of the Health and Community Care Committee offering to help the Executive. The key question is how best to do that. What questions do we ask? What information is reported and at what level is it reported? Some of the detail to which Richard Simpson alluded is available in the accounts of local health boards and NHS trusts. Therefore, it is possible for members to ask questions locally. Given that we all operate with finite time, energy and resources, I question the value of massively expanding the amount of information that we ask to be reported back to the centre to be aggregated at a national level. There are fundamental issues relating to how resources are allocated, how they are spent and how much reporting there is about how they have been spent. In Scotland we operate rightly on the basis that the lion's share of health resources and NHS spend is allocated to local health boards, which they decide how to spend.
I would be extremely wary of moving dramatically from that position. Having said that, I recognise that we can consider more effectively how to act more cohesively throughout the country on several issues. However, we must consider how spending decisions are taken locally. I point again to the performance management framework. I do not want that to say simply, "Thou shalt spend £X million." I want to set out the standard of service that we expect every part of the NHS in Scotland to deliver on such matters as diabetes or mental health and I want us to focus our energies on assessing that.
I will be frank with the committee. I am resistant to going much further down the road of a big data collection and financial monitoring exercise that would disaggregate the line that I described in the way that was suggested. However, we are always happy to consider the system as it evolves. When the committee discusses NHS modernisation and the health plan next week, I am sure that questions on performance management will arise. The committee might then wish to discuss further such issues.
One point that has cropped up in our discussions is the fact that we are investigating not only what a health authority is spending on a programme, such as on diabetes or coronary heart care, but whether there is a trend of change from acute to community or intermediary care, which the committee needs to see. If the Executive, at the centre, decides that an issue is a priority and that it wants to take forward a move towards change that the committee wants to support, the committee should see such change. At the moment, it is difficult for all committee members to see those changes.
Although some of the moneys that have been allocated are welcome, it is difficult for committee members to follow the health pound through to the point of delivery by local health boards. Some health board employees deliberately make that task difficult and remove any chance of having the transparency that the minister is trying to introduce into the health service. That gives us a political problem, because the message is not available locally.
I had discussions with Ayrshire and Arran Health Board this week about the money that was allocated for Arbuthnott. I tried to find out where that money would be spent, but was stymied at every opportunity. I accept that the minister does not want to continue to hold centralised data. I am an opponent of health boards continuing in their present form and I do not think that my view will change, but we need to ensure that health boards make available the information that we need, without Parliament or patients having to ask for it. That is how the accounts of health trusts and—need I mention them—independent contractors, general practitioners and out-of-hours GP services should be handled. We need to see what public funds are delivering, whatever the services are called. I think that that is the point that Richard Simpson makes. John Aldridge might not require that information, but it is definitely required at the point of delivery.
Margaret Jamieson raises several important issues, which she has put to me several times before. I agree with some of her general points and I share some of her frustrations. The Government faces some real issues.
The Government is pumping an extra £400 million to £500 million into the health service this year, next year, the following year and the year after that. We feel that, in some cases, that money is not getting through to deliver the improvements in services that we are investing in and that people demand. Those services are greatly needed and the solution to the problem lies not in our financial monitoring processes or budget reporting mechanisms, but in resolving some of the fundamental weaknesses in the governance and accountability mechanisms of the NHS in Scotland.
I have said explicitly, from the very beginning of the wide-ranging package of work and discussions on NHS modernisation that we have undertaken this year, that resolving those problems must be at the core of our work. We want to address that directly and specifically in the Scottish health plan in November. We cannot allow patients to suffer as a consequence of weaknesses in the system or because of the absence of effective decision-making and accountability processes.
I pay tribute again, as I constantly do, to the hard work of committee members. The Health and Community Care Committee was one of the few subject committees that made suggestions about where the Executive might like to spend some of those hundreds of millions of pounds of extra resources. I know that Dorothy-Grace Elder wants to pick up on one of those suggestions.
I have a question about the role of the voluntary sector in health and community care. The minister has paid tribute to the voluntary sector's vital role. In the past 15 months, every member of the committee has heard evidence—officially or individually—that there are issues other than budget levels to consider. As Margaret Jamieson said, some things are not apparent from the general budget. Insecurity of funding is a significant problem for voluntary organisations.
As the minister said, there is a danger of monitoring to such an extent that there is no time left to do anything else. The work of voluntary organisations can be considerably diluted by a constant battle for funds. Sometimes, a full-time officer is needed to do that and voluntary organisations often cannot exist for more than six months or a year at a time. Could the minister give the committee a pledge on security of funding for voluntary projects?
My second point is about raw cash. The Executive managed to obtain £26 million from the increase in tobacco tax, not from the overall tobacco tax. That was an innovative way of dipping into funds. However, in view of the fact that the Scottish tobacco tax haul is about £1 billion, of which £10 million is contributed, it is believed, by child smokers, can the minister assure the committee that she will try again to get more of the tobacco tax to fund health and community care?
I shall answer the point about voluntary organisations first. I share the view that the voluntary sector will have an immense role to play in the delivery of effective health and community care services in future. The tragedy is that, all too often, insecurity and uncertainty about funding stands in the way of effective delivery of voluntary sector services and can, in the worst cases, lead to organisations folding.
To the extent that we can address that problem at national level, we are doing so through the voluntary sector compact. We have increased the grants that are available to voluntary organisations by £1.5 million, as set out in our spending review commitments for next year. We must also ensure that local funders—health boards and local authorities, in the main—give local voluntary sector bodies the attention and priority that they deserve. A number of developments that are under way, such as community planning, can help them to do that. That will create cohesion between different agencies under the leadership of local authorities, so that agencies can come together and make a better assessment of the needs of local communities.
I hope that, thereafter, the statutory bodies will work more closely together than has sometimes been the case, on how those needs can be met most effectively. If a broader perspective is taken, needs can often be met as effectively or more effectively by a voluntary organisation. I repeat that the Scottish health plan is where we want to make explicit the role that the voluntary sector ought to have in the future development of health and social care services. I see that sector's role as central.
Dorothy-Grace Elder asked about financial issues. The £26 million that we have identified for public health is part of a much wider increase in the resource that has flowed to Scotland, not only for health, but for the entire Scottish block. As I said a moment ago, that has resulted in an increase of between £400 million and £500 million not just this year, but for the next three years. Without wanting to go into the constitutional issues, which I think Dorothy-Grace Elder touched on, I believe that Scotland has benefited enormously from the fact that the UK economy is in good shape and is being managed effectively. Substantial additional resources are available to us to spend as we see fit. We will continue to ensure that the health budget and budgets and activities across the Executive keep working to improve the health of Scotland. We are active in that respect.
In bringing this item to a conclusion, I ask for clarification on the two specific issues that the committee asked about—grants to voluntary organisations and the uprating of the mental illness specific grant. What have you decided to do?
I breathed a sigh of relief there. When you emphasised that you had specific points, I was sure that I would not have the details to hand, but I can say that those two issues are specifically identified as having been addressed in the publication "Making a Difference for Scotland: Spending Plans for Scotland 2001-02 to 2003-04", which the Minister for Finance published a few weeks ago.
As I mentioned, we are increasing the grants that are available to voluntary organisations by £1.5 million. Similar increases are taking place in budgets for voluntary organisations in specific areas, such as drugs. We have also given a commitment to increase the mental illness specific grant by £1 million a year, while at the same time considering how to make that grant more effective.
The final point that I want to make, which I did not mention earlier, is that we have not provided further level III figures to the committee as requested, because we want to ensure that spending and investment planning is linked to our policy development process. We see the health plan, which is to be published next month, as the point at which the two things will come together. I am sure that the committee will want to ask further questions and have further discussions on that, and I hope that the committee will contribute to the process between now and publication of the plan.
We will conclude our discussion on the budget later this morning, after we have released you, minister.
I bring this item to a close. I thank the minister and her officials for attending. We have covered a fairly sweeping range of items of business, some of which we have done a lot of work on. I thank colleagues for the work that they have undertaken to date. We will do further work on some of those areas. We will return, for example, to hepatitis C, as well as to the Arbuthnott report, on which the committee will take a final position. As I said, we will examine the budget further this morning. Thank you, minister, for your input.