Health Committee, 28 Oct 2003

Meeting date: Tuesday, October 28, 2003

Official Report 187KB pdf

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Budget Process 2004-05

Item 4 on our agenda is the budget process. Dr Andrew Walker, our expert adviser, will take us through this. I am grateful to him for guiding us through the quagmire that is known as the budget—at least, it is a quagmire for me. I will leave Andrew to deal with it as he thinks appropriate. Members of the committee may comment on parts of the paper that they want to amend. We will go through the paper paragraph by paragraph. Andrew, you do not have to read it out—you need only highlight the main issues.

In effect, members have two papers in front of them. One is a reply to the seven questions that the Finance Committee asked us to answer. The other started life as the introduction to the first paper and became something slightly longer and more involved as it progressed.

Andrew Walker is referring to paper HC/S2/03/10/3. The two documents have been amalgamated in one. There are not two separately enumerated papers.

The replies to the seven questions that we discussed previously appear from paragraph 14 on page 7 of the paper. The preceding part of the paper started as an attempt to explain to the Finance Committee some of the frustrations that the Health Committee has felt when trying to understand how the £5.5 billion that goes to national health service boards has been used, but developed into an attempt to explore the issue further.

On my way to the meeting, members asked me whether we wanted to include the whole introduction in our reply to the Finance Committee. The answer to that question is almost certainly no. However, because we are now focused on the budget this would be a good time to think about whether we want to proceed in the same way next year. Do members want to deal with the seven questions before discussing the introduction?

Members are indicating that they would like to deal with the seven questions first.

The section on the seven questions, which starts at paragraph 14, should be relatively straightforward, as it reflects our previous discussion. The paper works through the recommendations that the Health and Community Care Committee made in the first session and seeks to ascertain whether those have been addressed. The first recommendation appears on page 7. I will not read out all the recommendations, but members may comment on individual parts of them. Should we move straight to the recommendations that I am making this year?

Members indicated agreement.

I recommend that we repeat some of the recommendations that were made last year, so that action may be taken on them this time. The first recommendation, in paragraph 27, is that we again ask the Executive to respond to previous recommendations 1, 2, 3 and 8, which are about making more accessible information on how health boards spend their money, on postcode prescribing and on public involvement. We all recognise that the Minister for Health and Community Care is committed to public involvement, but something more specific is required. I could have asked the committee to repeat all 10 recommendations, but I judged that recommendations 1, 2, 3 and 8 were the most important.

Do paragraphs 28, 29 and 30 accompany your first recommendation?

Those paragraphs are about the Arbuthnott formula. I stopped at the first recommendation so that we could deal with that. I suggest that we repeat recommendations 1, 2, 3 and 8. I then make some specific points about the Arbuthnott formula.

Is the first recommendation agreed to?

Members indicated agreement.

As the convener points out, in paragraphs 28, 29 and 30 I tried to pick up on the comments that we made about the Arbuthnott process. The recommendations are in paragraph 30 on page 11—I hope that I have captured the flavour of what members wanted to say. In the third recommendation, about specifying how much each NHS board gains or loses as a result of its demography, deprivation and rurality, we need to make it clear that we want separate figures for each of those factors in each board, because the Executive could construe that as one figure.

We need to amend that.

Just an amendment. There are a number of small typos through it—

What do you suggest that it should say?

We should be asking the Executive to supply data on the financial allocation to each NHS board, showing how much each board gains or loses as a result of first, socioeconomic deprivation; secondly, rurality; and thirdly, demographic structure. That is to make it clear that we want to know each bit of information for each board.

In order to know what losses and gains there are, there has to be a baseline. What would you use as a baseline?

It has to be relative to Scotland. We would be saying, for example, that although the Scottish population has a given demography, some areas, such as the Borders, have more elderly people. How much more does the Borders receive as a result of having more elderly people than the Scottish average? Is that what you mean?

I assumed from the way in which that last recommendation was written that you were talking about gains or losses in relation to NHS boards' financial allocation at a given point in time. What would the baseline be for that?

I see what you mean. So, perhaps for the current financial year, 2003-04—

We are talking about trying to work out, from the period before Arbuthnott, what percentage each board had. In order to find out the actual effect presumably you would need to have very specific figures. A bit more information is needed in that recommendation or we will not get the answers that I thought the committee wanted.

I understand what you mean, Kate. Sorry, I had thought that you wanted to know how much more Grampian, say, received as a result of its geography compared to what it would receive if it had the Scottish average geography. [Laughter.] Sorry, I was just testing to see whether members were still listening.

You just mention Grampian and you go all Pavlov.

On the back of what Kate Maclean was saying, we receive information on outcomes and outputs so late that it is difficult to assess them annually. I suspect that it will have to be done on budget rounds of three years or so because that will be the only way in which we can analyse trends. Do you see what I mean?

Yes, I think so.

We must compare with outcomes—in other words, not just what was spent in cash terms but what actually happened. I thought that we were going to have some comment on the Arbuthnott effect on core service provision. Does the fact that health boards have to meet targets relating to socioeconomic deprivation, rurality, demography and so on have any effect on their ability to deliver core services? How does it compare with that ability in the past? That may get support from those who come from the north-east. The point is that if we are going to ask for information, we have to do so in a meaningful way and our request should refer to something.

Sure. Sorry, I had not picked up on your point about core service provision, which also raises a question. To stick to what it says in that last recommendation at the moment, however, are we asking for information about the current financial year—which is what I had envisaged—or, as Kate Maclean suggests, information about before and after the Arbuthnott formula was introduced?

Sorry, it is not clear.

You are right—it is not clear.

Are we are looking at what percentage each health board area receives for those factors, or are we looking at how much health boards have gained or lost since money was distributed, or partially distributed, under the Arbuthnott formula?

Rather than deal with this on the spot we could come back to it next week. Are you available?

I was just checking whether the report is supposed to be at the Finance Committee for next week.

We have another week.

Just to clarify, there are two views on this. One is that we should use this financial year and the other is that we should use before and after Arbuthnott. What would members like?

I do not mind.

Do we have a political problem here? Everybody gains with increased investment, but the report says that there are gains and losses. The Arbuthnott formula builds in something to take account of a particular area of need so that more money is made available for that area of need. Money is not necessarily taken from somewhere else. The alternative to such an approach would be that a rich and healthy area would want to take money from a poor and deprived area in which people are dying.

How funds were previously distributed should be known. We can get information for the previous financial year or the previous couple of financial years, but I presume that other indicators or methods have been used for distributing money to health boards. If we do not know how money was previously distributed and whether the Arbuthnott formula has helped or hindered specific areas, it is difficult to see what the point would be in having information only about funding percentages over the past year or couple of years.

In any given financial year, some boards will lose. A particularly affluent area will have less money than it would have if allocations were based simply on a population split. That is what I meant by gains or losses. There will be a different allocation if the population in an area is young to middle-aged or if the area is a concentrated urban area, as a result of the factor of rurality. In that sense, there will be some losses. I suggest that the solution is that we ask both for information on the current financial year, which will show us something, and for a before-and-after picture. Perhaps I am trying to cram too much into one recommendation.

It is important that we ask for such information and I hope that we will do so. I assure Duncan McNeil that, regardless of our personal views, if any MSP from the north-east goes to Grampian NHS Board briefings, the view of most health professionals in the north-east will be made absolutely clear. They see that the Arbuthnott formula has clawed back from Grampian money that would otherwise go to Grampian and they talk about cuts in services, albeit that the Scottish Executive has given a funding increase over and above inflation. The issue relates to perceptions.

I do not want every member's constituency to be discussed and pitched against one another. However, we are trying to get comparisons and a framework.

The issue does not relate to any one board. There is a perception difficulty with the Arbuthnott formula throughout Scotland and not just in the north-east. I have heard things that have been said in other parts of the country, too. We should do anything that we can to bring clarity to the process. If money is allocated through Arbuthnott for specific areas, such allocation should be seen to be delivering additional benefits and not to be at the expense of core service delivery. There is a perception that such allocations are at the expense of core service delivery.

Andrew Walker will round off the discussion once Shona Robison has said something.

I do not know whether I am the only person in the room who is confused.

No, you are not.

For the adviser's sake, we need to be clear about what we are asking. The starting point should be what the committee is trying to find out. I thought that we were simply trying to find out whether the factors that are listed are being properly taken into account in the allocation of funds. To return to what Kate Maclean said, what is the best way of determining that they are? If that is what we are trying to find out—which I take it that we are—what advice can the adviser give us about the best questions to pose to get such information?

I was trying to say that the answer to this question would give us the information that health board X gets £400 million, gains £10 million on the deprivation part of the index, loses £5 million on the rurality part of the index and gains £2 million on the demographic part of the index. We could then see how each part of the index played in. I was going to do that for the current financial year because I thought that that was what the committee wanted.

I would find that helpful.

Do members agree with that?

It gives more clarity.

For the current financial year.

On David Davidson's comment about the effect on core service provision, could I add to the report that the committee is concerned about that and seeks reassurance? I am not quite sure how to phrase that, but it has been raised.

We are seeking clarity rather than just reassurance.

I predict that the Executive will say that it is up to local health boards how they spend their funds.

Is the issue not much wider than core service provision? It is not just about money. We are still discussing where we put planning and the availability of staff into our work programme.

You are looking at me, convener.

I am just wondering whether we should leave it as it is at the moment and you could raise the issue again next week. We could then move on because this is not the final shot at the report.

That is fine.

The point that I was making and that created that discussion was that the wording is not clear about what we are asking for. We did not really have to have that discussion; we just had to clarify the wording.

We have got that and will clarify that it is for the current financial year. If we are going to deal with core service provision, we can talk about it at next week's meeting. Let us move on.

Question 2 was about the partnership agreement and whether the committee was content with the additional funding proposals. In paragraph 31, I have quoted from the minister's letter and paragraph 32 lists from the Official Report the reasons given as to why the information is not in the draft budget. Paragraph 33 refers to column 231 of the Official Report and says that we are aware that few details are available, but the recommendation says that we would like those details to be made available as soon as possible. The final sentence of the recommendation states:

"The Executive is requested to write to the committee stating an anticipated date"

by which all those details will be made available.

We have all ticked that.

Members indicated agreement.

Question 3 is the shortest one on the list because it is about end-year funding and, as has already been pointed out, the Official Report shows that the £24 million of EYF has gone into the boards' allocation and been carried forward. It has not been earmarked for a specific purpose. It seemed to me that the committee would be content with that. Is that okay?

Members indicated agreement.

Question 4 is about the programme budgets and whether we want to change them. I have made a point about the lack of information on outcomes and I quoted different examples, such as research and cancer services. The minister made the point that his life was quite difficult because he had to make such judgments, but if he had some information on outcomes, it would be easier to make such judgments, although I accept that there can be problems with that.

Last year, we asked the Executive to look into providing information on outcomes and to set out a timetable. The recommendation that I have made this year is that the Executive should respond to those requests.

I have ticked that.

It might not be possible to do that, I accept.

The Executive should at least try.

It would be nice if it explored the possibility because the £7.5 billion is supposed to be making people better and, at the moment, we do not know that it is.

Question 5 asks:

"Does the Committee feel that the portfolio priorities are appropriate and are reflected in the budget proposals?"

David Davidson asked the minister a question about that and the minister replied that he would be very surprised if the two lists were not the same. I have done a new table and found that the lists are almost, but not completely, the same. There are some surprises; for example, waiting times appear in one list but in not the other. Although there is a good core of overlap with service redesign, cancer services, heart disease and mental health being on both lists, there are some differences. However, I was not sure whether the committee wanted to make any recommendation other than to say that it is a bit surprised. Would members like to suggest a specific recommendation or are they happy with it?

You are not looking at the recommendation on page 16. What does that relate to?

The next recommendation relates specifically to target setting. I did not make a specific recommendation on the difference between the portfolio priorities and the national priorities. Do we want to make one? I do not think that it will change much, to be honest.

It is important to draw attention to the fact that they are different.

It is just that the minister said that he was surprised, as he did not think that they were different at all, but I think that they are quite different.

This is a daft-lassie question, but will the useful little table be in our report? The minister will have that in any event, so it will be quite useful to draw his attention to things that are not matched.

The paper that is before you is a draft of what will go to the Finance Committee.

That is fine.

Paragraph 41 on page 15 repeats what you saw back on 23 September, and it links the different portfolio priorities to bits of the budget. Where further evidence has become available—such as on the number of nurses recruited—I have included that, although there was not too much additional evidence.

On abolishing NHS trusts, I saw the Finance Committee trying to get out of the Executive how much it believed the cost of the reforms would be, and I noted that it was not easy to estimate. I think that there are still scorch marks around the witness seats.

The problem is that we cannot clearly link the priorities and the budget together because, according to the Health Department, the priorities overlap so much. It is difficult to see how we can say that we are getting best value out of the budget if we cannot see exactly what is going on. I was surprised to read in the Official Report that the chief executive of the NHS was saying that he could not tell how much the waiting time initiative cost; that seems an extraordinary state of affairs.

The main problem, on a pragmatic budget-monitoring level, is about the idea of setting SMART targets. If you do not have a SMART target, you cannot easily monitor whether anything much is being done.

For the record, could you say what a SMART target is?

I apologise. SMART stands for a set of principles—targets should be specific, measurable, achievable, relevant and time-limited. Those should be the characteristics of a target, so that it is a precise, quantified, measurable target and so that you can say at some point in time whether or not you have achieved it. There is a tendency not to set targets in that way. The recommendation of that rather long section is that all future targets should be in that form.

Are members content with that?

Members indicated agreement.

Question 6 is whether the committee is satisfied with the performance information contained in the chapter and whether it feels that the links between aims, budgets and targets are properly integrated. I do not think that there is an awful lot that is new here, although this is where the bit about the nurses came in. I wondered about mentioning the new delayed discharge figures, but have just said that we have noted that they are up a bit and are not quite as good as they used to be. After that, I have said more about SMART targets, which is a fundamental point. That is where the point about cancer waiting times came in.

The minister's response to that, if you recall, was that, first, the Executive knew that the data were not perfect and, secondly, officials had spoken to clinicians, who thought that the targets were probably achievable. Well, a basic requirement of setting a target is that the people involved think that it is achievable, but the Parliament will want to monitor progress on that target, so we really need some data to get that together. The first recommendation is therefore that

"The Executive take urgent steps to review and improve the data available for monitoring the cancer waiting times targets."

The second recommendation reiterates the point about SMART targets. Is that okay?

Members indicated agreement.

Paragraphs 51 and 52 talk about integration and the problems with ring fencing. The recommendation states:

"For accountability purposes, the Executive is urged to find ways to at least estimate the cost of its policies."

I do not think that we can go on saying, "We don't know what the waiting times targets cost." It could be that a quarter of the NHS budget has gone on that; we just do not know. I have suggested that the committee ask for evidence of progress in that direction in the next budget document. We recognise that the Executive cannot crack it immediately, but we cannot go on like this.

I am slightly hesitant about that because demand cannot always be known in advance. In any demand-led service throughout Scotland, whether education, housing or health, for which there is an unknown public demand, it is extremely difficult for the Executive to respond and to set a precise budget. However, the Executive does its best to respond to all demands that are presented to it.

I recognise that, which is why I would never assume that more than an estimate was being made. We cannot even know precisely in retrospect. Trevor Jones's point was about how far a hospital bed is accounted for by waiting times. I recognise that that is a problem and that we have no idea about the answer just now.

Are ministers in other legislatures able to find a way of estimating and monitoring the cost of their policies?

I welcome others' views on this, but my understanding is that, compared with what happens in Westminster, we get more information in the Scottish Parliament, which makes us hungrier for more.

I was thinking of Europe rather than Westminster.

In that case, I do not know the answer.

If you cannot answer the question, you cannot answer it.

My understanding is that there is far more information in the Scottish Executive budget than there is in the National Assembly for Wales or Northern Ireland Assembly budgets. That is also the case in comparison with Westminster, as Dr Walker said.

I have a quick comment in response to Helen Eadie. We must bear it in mind that the Executive set its own targets. I assume that in doing so the Executive took into account the fact that pressures can materialise in different ways at various times. Nevertheless, the Executive set the targets and we are obliged to measure the progress made towards those targets. However, the problem is, as the adviser outlined, that the data are inadequate. The Executive must surely address that issue.

That is a fundamental question for any management system or process, whether it is a government one or not. We referred earlier to another part of the budget document that dealt with costings for the partnership agreement for the next four years. The costings have not all been published yet, but they have been done. I am sure that the Executive has information on that and on other issues that are running, but such information is not yet in the public domain. I do not believe that there is any conspiracy to keep such information from the public. It is important to know what any management tool costs and it should not be difficult for the Executive to present information about costs.

The first sentence of our recommendation ends with "cost of its policies." To clarify what is being sought over time, I suggest that we add "and targets within the budget document."

We are just asking for an estimate. We do not want to pin anything down in accountancy terms. We are asking the Executive only for evidence of progress rather than for a solution or a straight answer. We just want to see that progress is being made.

There are targets in the budget. I suggest that there is more—

We are concerned with costs.

David Davidson referred to targets in the budget document.

No, the phrase that he quoted was "cost of its policies."

I want to add to that "and targets within the budget document." I know that that cannot happen overnight, but I am asking the Executive to consider it for the future.

We will return to that point. We will not return to what we have agreed on, but we will underline and highlight the parts of the document to which we must return.

The final question is number 7. Does the committee have any comment on the sections that cover the cross-cutting issues of closing the opportunity gap, sustainable development and equality? I have separated out sustainable development and equality as being generally helpful. I suggest that we recommend that the Executive do a bit more next time in those areas, although our recommendation might open up a philosophical debate about what we mean by equality. However, perhaps the Executive should try to come up with something for those areas that is linked more coherently to the budget than it was this time.

I think that it involves equality for Grampian somewhere.

No comment.

In contrast, I felt that it was good that someone was looking at sustainable development, but I did not think that we would want to spend a lot of time on it. Are members happy with that?

Members indicated agreement.

I take members back to the beginning of the report, where I start to explain to the Finance Committee and to people who do not know much about NHS finances why it is so difficult to get into the £5.5 billion that goes to NHS boards. I have tried to explain the data that are available, going through the performance assessment framework, local health plans and the Scottish health service cost returns. I spell that out on page 2.

At the bottom of page 2 and the top of page 3 I have included a wee table. It does not work very well, because it has been split in two, but I was trying to say that in six months' time we will be sitting in a committee room somewhere—or members will, at least—trying to scrutinise the next draft budget. So, at the start of 2004-05, the year that will be of interest and which we will be examining for the budget will be 2005-06. The performance assessment framework will have data from the previous two years and health service cost returns will have data from the previous two years. Local health plans will have some data for some health boards, but probably only on growth moneys for the next year. I see that as a problem that just moves on from year to year. We will never get the data that we want. Matters are not the way that we assume they will be.

In paragraph 7, I pick out two examples from the oral evidence. The first is about the cancer budget. The Minister for Health and Community Care said he was really pleased because, unlike in England, we can track how all the money has been used. The convener pushed him a little bit harder and asked what outcome we are getting, and from reading the Official Report—I was not present—it appeared that the minister became slightly more uncomfortable when it came to saying what the money had actually achieved. The second example is the waiting times budget, where I picked up on the chief executive of NHS Scotland's comment.

Paragraphs 8 and 9 are my personal interpretation, which is that we seem to use the money to set up an infrastructure for care that includes staff, equipment and buildings, then we rely on clinicians to do the best things for their patients within that. However, as a committee scrutinising the budget, we tend to assume that there is a plan somewhere that says, for example, that Fife NHS Board will spend X million pounds on cancer services in two years' time. My impression from having worked in a health board is that at that level planning simply does not exist. It is not quite as chaotic as I might be implying, but it is the product of lots of individual decisions that add up to a cancer service. It is a bottom-up system, but we are assuming that it is a top-down system.

I started thinking that if that is the case, we are always going to be frustrated in trying to get people to reveal what their plans are, so what are our options for doing something about that? In paragraph 10 I set out five different options that we could adopt. Option 1 is to continue as we are, which is to keep trying to get information out of the Executive. There is so far no evidence that we can find anything terribly useful to ask, and no evidence so far that the Executive will go further than to say that it is up to health boards how they spend their money. We are all going to be quite frustrated.

Option 2 is to try to bring the performance assessment framework into the process and to look at the broad direction of travel over time to judge what health boards are doing and whether the various indicators—I think that there are about 100—in the PAF are moving in the right directions over time. That would not give us micromanaged information and it would not give us fine-tuned information, but it would give us broad directions of travel, which might be all that we should have.

The third option is that the easiest way to engage with the health service—because it is the way that it thinks most naturally—is in terms of the inputs, such as the numbers of doctors, nurses and other staff, the number of beds, the number of buildings and so on. We could try to monitor that at local level and ask which direction it is moving in. That would have some advantages, because everyone feels quite comfortable talking about more doctors and more nurses and many targets are set in such ways. The downside is that using inputs is not specifically about how many people are getting healthier. We might assume that more doctors leads to better health, but the equation is not simple.

Option 4 is to examine historic spend, which we can do from the hospital cost returns from two years ago. We can then assume vaguely, given time trends, how things are going to be in two years' time. That involves a bit of extra work, but it gives us some quite fine-detailed information. Members might remember that I had an A3 sheet with me on 23 September, which showed some more information from Greater Glasgow NHS Board. We could drive that on a lot further for all the health boards, but the information would essentially be about what happened two years ago and we would be using that information to make assumptions about what will happen in a year's time.

The final option concerns proxy outcomes, whereby we identify the health services that give high levels of health gain for the amount of money that is spent on them and then identify another group that give quite low value for the amount of money that is spent on them and try to monitor where the health boards are moving into the first group and out of the second group.

In paragraph 11, I have included a wee table that tries to summarise all that information. The options are listed along the top and I ask various questions about them. The first question is whether the option would allow us to comment on NHS board allocations, to which the answer is no or yes. The second question is whether health gain is central—I am assuming that health gain is fundamental to what we would do under each of the options. The third question is whether the option relies on retrospective data, which I take to be undesirable. The fourth question is whether additional effort is involved in preparing the information and bringing it together, which is generally undesirable. The fifth question is whether the option would encourage dialogue between the Executive and the NHS, which I am assuming would be desirable for present purposes. I have set out how I perceived that each of the options performed against each of those questions.

I am sorry that that has been slightly long-winded. I regard the document more as a discussion document than as something that might be sent to the Finance Committee. The Health Committee might want to take this opportunity to think about where we want to be in six and 12 months' time and whether we will be frustrated because we still will not have any information on how we could do better next time. I will now pause for breath.

This is beginning to get to the crux of some of the debates that the committee has had time and again. Dr Walker has put a lot of work into the document, which is extremely complex. There would be nothing to stop us from recommending a combination of the options. I am quite taken by option 3—the inputs option—along with the proxy outcomes option.

The inputs option relates closely to the committee's inquiry into the impact of the centralisation of services and the driving forces behind that. It would allow us to see, for example, where moneys that were supposed to be allocated for new services were not being used for those services, but were having to be used to address some of the pressures on staffing costs. Would it allow us some transparency in having a look at that? Anecdotal evidence from around Scotland suggests that that is what is happening because of pressures on budgets. Would that option give us evidence of the degree to which that is happening?

The proxy outcomes option would also allow us to compare good practice and bad practice in determining the best use of available moneys for specific services—cancer services, or whatever. The comparison need not necessarily be made across the board. It would be interesting to see how health boards had used the money to get specific outcomes and where health benefit could be measured to a greater degree.

My preference would be for us to recommend a combination of options 3 and 5. I think that the document is a good piece of work.

Thank you.

I agree. This is a complex piece of work and it is helpful for us all to have it. We are always being critical of the Executive and others for not consulting people, but the issue for us is how we can consult the wider public about some matters as well. Clearly, we are trying to improve things for the future. The question is; what can we do as a committee to consult the wider public? We always consult the clinicians and medical people, but we do not always consult the users of the services and others. That is a key point.

According to the way in which you have presented this—you have included a box at the end, with lots of ticks—the proxy outcomes option seems to be a particularly attractive option. Obviously that view might change with further consideration and on hearing other members' comments.

I warn Helen Eadie that the proxy outcomes reflect my personal prejudices. As a result, members should exercise suitable discretion.

I guessed that.

That is on the record now, Andrew—you are being far too honest.

I agree with Shona Robison and Helen Eadie that the inputs and proxy outcomes options are good ideas. I am very happy to agree to them.

However, given that this is a draft report, I am a little bit confused about how we are going to present it. Do we intend to issue it as an introduction to the seven questions? Moreover, Dr Walker, are you asking us in paragraphs 12 and 13 to firm up a preference? I am not quite sure about what you are trying to get us to do.

That is a fair question. After all, the document kind of evolved. The report from paragraph 14 onwards will go to the Finance Committee. However, the discursive part of the report—which we are now discussing and which perhaps includes paragraphs 8 and 9 and the various options that are outlined in paragraph 10—will probably not go into the final report to that committee. As a result, the report could include up to paragraph 7 and conclude that although the committee felt a certain amount of frustration about the level of detail, it acknowledged that there were difficulties. I propose that the report to the Finance Committee exclude paragraphs 8 and 9, which are based on my interpretation of the matter. It should also exclude paragraph 10 until the committee is sure what it wants to do.

I think that that part of the report is very good. If we were going to send the report to the Finance Committee, we would have to state our recommendation in it. That section gives food for thought, because it clearly suggests a way forward that is not currently being explored, and which would provide us with some—if not all—of the information that we feel we been lacking and which would enable us to track where the money goes, how it is spent and the health benefits that derive from it. Although such an approach is not perfect, we could suggest to the Finance Committee that it form a starting point for discussion. I do not want that part to be lost from the report, because it is very good.

Like Mike Rumbles, I am attracted to the inputs and proxy outcomes options set out in the paper. However, I sense that the committee does not feel confident about making a decision, although I might be wrong about that. We have got a cut on the issue and I agree with Shona Robison that we have reached the crux of the matter. If such an approach is successful, we will be in a better position to examine the value that we are getting from the money that we are putting into the health service. We should consider taking a cut today and addressing that particular point the next time around.

Unless I hear to the contrary from the next two members, I think that the committee is in favour of the inputs and proxy outcomes options. I have not heard any member speak against them yet.

I think that we are in favour of those options. However, I agree with Duncan McNeil—I have not had a great amount of time to look at this part of the report, which is why I asked whether it was also going into the report to the Finance Committee. I am not sure that that should happen.

That is not a problem, because we will have another opportunity to go through the report and redraft parts next week. The report will take on a different shape after we remove the questions and so on. Like you, I was not quite clear what was going to happen in that respect. However, we have taken decisions in principle on certain issues such as the inputs and proxy outcomes options. We have still to hear from two other members. The presentation of the report and other information that should be included are still open to discussion.

As we have pointed out previously in the committee, an awful lot of extra money has gone into the health service over the past few years, but no one seems to know where it has gone and what we have received for it. The public are asking questions about outcomes. We should focus on inputs and outcomes, as opposed to outputs, and see whether we can get something from that.

I cannot comment on the Finance Committee in this session, but certainly during the previous four years it was concerned with considering what outcomes had been achieved across the budget in all areas. Information was a problem. If we are trying to sing from the same hymn sheet today I believe that we should take options 3 and 5, or a combination of them.

I would hate to see the report being lost, because the information in it is tremendous; I was particularly glad to see the table. I also marked the inputs and proxy outcomes options.

We owe it to the people whom we serve to find out more. Before the away day, I presented figures that had been gathered by another doctor. The figures proved that from 1999, for all the extra money that was put into the health service, activity was falling off. In such a situation, a business would not plough money in. It is easy to say that more money has been spent in the health service, but we are confronted with an increase in the number of people lying around on trolleys and wondering where the beds are because they have no beds to go to. At the weekend, someone told me that because there was no money for it, he could not have an operation, which I would have thought was required urgently because he has such a miserable condition.

We owe it to the population that we serve to try to find out more about how our money is spent. That is not a criticism in a nasty sense; I think that everybody in the Executive is trying to do what is best. They cut up the money and hand it out to the health boards, but we do not know how the money is then spent. We have to work on outcomes. I wholeheartedly support the proposals and we should try to hand on as much of the document as possible because it is thought provoking.

We all want to try to track the funding.

Yes. If we examined that carefully it might save us money in the long run—if that is possible.

What is spent on an input or an outcome is a small amount of money in the total budget. We know where 70 per cent or 80 per cent of the budget goes; it goes to pay salaries.

That is another issue for later.

It is not only a general point. We have had the debate before about what we could affect in terms of the overall budget. There is no point in our doing a lot of work on certain matters—for example, if we did not agree the consultant contract and this contract we would make more money available, but we would also disaffect staff and so on. I do not know what part of the budget we are focusing on: is it the whole budget?

I think so. We are considering, for example, the number of consultants that a particular health board employs per head of population or the number of GPs or nurse specialists of a particular type that it employs.

I am mindful of Shona Robison's question about whether the information will show us whether money for new services is diverted to plugging gaps. I am not sure about that; I must consider exactly what this means. My slight wariness about the whole exercise is that we now have a statement of direction and intention, but we need to see more detailed information about what that will look like in case it becomes all things to everyone.

At the end of the day, that is where we are going.

It will give us more to debate than we have now.

We are talking about the whole budget. The proxy outcomes option would measure the health outcomes from money spent on staff. It would not measure the outcomes from only 20 per cent of the budget—it would relate to the whole budget. If the proxy outcomes option was adopted as a way of looking at the budget, there would be a way of measuring the outcomes.

I suggest that Dr Walker come back with something next week to show how the information would be presented. We could have another look at it then.

I ask Dr Walker to provide the information in a digestible form that will almost be what will—subject to any amendments that we make—go to the Finance Committee. We could see clearly what is going into the report, so next week we would only tweak it. I think that Duncan McNeil wants to say something.

The adviser has been given a clear steer, so do we need to go on?

Fine.

I feel like the Presiding Officers, because we intended to stop at 15:30 and I could almost do what they do when they talk until decision time; however, that now brings today's meeting to a conclusion.

Meeting closed at 15:29.