Health and Community Care Committee, 31 Oct 2001

Meeting date: Wednesday, October 31, 2001

Official Report 311KB pdf

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Budget 2002-03

Good morning everybody, and welcome to this morning's Health and Community Care Committee. The Minister for Health and Community Care is not with us this morning; we send her our best wishes for a speedy recovery. Malcolm Chisholm is here to answer questions on the budget in her stead. I am sure that he is looking forward to that. We also have John Aldridge—I think that this is all part of a plot by John to be the person who has attended more meetings of the Health and Community Care Committee than anybody else. We look forward to hearing his answers to our questions.

However, before we get into those questions, I want on behalf of my committee colleagues and myself to put on record our concern about the fact that answers from the Scottish Executive health department to questions that we asked in advance of this meeting were received only at about half-past 4 yesterday afternoon; I received those answers and then circulated them to committee members and our budget adviser Andrew Walker. As a result, Andrew was still working on those answers and on his work for the committee at 10 o'clock last night; he was unable to circulate his work to committee members until this morning. That is why we have started a little late.

Had this been the first occasion on which such a thing had happened, committee members might just have accepted it because our request went to the department only on 18 October and we appreciate that the department is very busy. However, on every other occasion on which we have asked for information from the department in advance of a budget meeting, the response has arrived at the very last minute. We do not have squads of staff behind the scenes to assist us in our work; it is very much up to members to formulate their opinions after having seen information and answers that we receive. When information that I request does not come in until half an hour before the end of the previous working day, I must say that I feel as if I am working with one hand tied behind my back.

I could go on more about this—perhaps it is just as well that I am talking to you this morning and that I did not do so at half-past 4 yesterday afternoon. I have made my views known to the deputy minister and, indeed, to the minister at a meeting I had with her last night. I have been urged by colleagues to put these views on record. That should be taken as an indication of how unhappy we are.

We are happy to accept the offer that the minister made in a letter, for senior officials from the Scottish Executive health department to meet members of the committee to explore the options for mutually acceptable future improvements to the budget document and the budget process. The committee would like to be as helpful as it can. When we ask questions, we genuinely just want the answers; we are not trying to trick anybody. Committee members want information so that we can give a reasonable response to the Finance Committee on a complex and important issue. Malcolm Chisholm knows, and we know, that the health department is a significant spending department. We must ensure that our scrutiny of the budget is as good as it can be, bearing in mind the limited numbers of committee staff.

The committee does not find the amount of information that we receive or the time when we receive it to be acceptable. We would be happy to work with the health department in future to improve the situation. However, the same thing has happened in October 2000, May 2001, August 2001 and now October 2001. That should be viewed against the backdrop of the committee having an incredibly heavy load in terms of legislation and other work. I hope that what has happened will not happen again.

I would like to respond to what you have said, convener. First, I pass on Susan Deacon's apologies. She has been unwell through the night and regrets that she cannot be here. I would also like to give an apology on behalf of the department. I am not going to try to justify the fact that you did not receive a reply until yesterday afternoon—I have noted the points that you made and I will ensure that it does not happen again.

I am glad that you have welcomed the health department's response about dialogue with the committee. I understand that the committee would like to address outstanding issues on the information and format of the budget document. We will be pleased to discuss those issues with you.

By way of self-protection, I would like to apologise in advance. I did not know that I would be coming to the committee until less than an hour ago, so I am perhaps not quite as well prepared as usual.

Members have been instructed to treat you gently—not too gently, but a little. We all appreciate that you have been drafted in at very short notice and that you have not had the same amount of time to prepare as your colleague would have had.

I do not remember any agreement to treat Mr Chisholm gently. He will forgive me if I break that agreement.

My first question relates to the decision-making processes in the health department. One of the questions that the committee asked was how you reach decisions about the allocation of new money. The answer that we received last night at half-past 4 gave a valid justification for each of the five areas to which the new money that was announced in June was allocated. Nobody in the committee is denying that any of those areas represent worthy causes. However, the point that the committee was making is that they are five out of dozens or perhaps hundreds of worthy causes. We would like you to talk us through the decision-making process that leads to the selection of one worthy cause over another. On what evidence do you base decisions that spending money in one area will have greater benefit than spending it in another area?

I will begin by answering most of the questions and will then pass them to others for further comment.

The questions go to the heart of decision making in the health department, the Executive and the Parliament. So much of what we do is about relative priorities. We ranged over many important areas in the months before the decisions were made. At the end of the day, a judgment must be made.

Examples such as the cancer strategy leap out; it represents one of our three clinical priorities. We published the strategy during the summer. That was an easy decision to make, in a sense, because we must assign money to that. Susan Deacon will make an announcement next week about how the extra money for the first year of the cancer strategy is being allocated.

We are aware of the amount of interest and activity that there has been in work-force issues in general in the Parliament and particularly in nurses and their recent campaign. Given the importance of nurses and of recruitment and retention issues, nurse bursaries is clearly an important area.

The third area that I want to flag up is primary care. We are committed to a primary-care led NHS, so it is vital that there are developments in primary care, particularly in some of the key priority areas.

We are not saying that there are not many other areas in which money could be spent but, after long consideration of the various issues, it was not too difficult to decide that we had to put extra resources into those three priority areas. The extra money that came through from the Westminster budget arrived in good time to meet those demands.

We should stand back a wee bit. We must consider two issues when we are allocating funds to the NHS. The first is the cost of maintaining the existing level of service. We must take into account forecasts of inflation and the potential costs of pay awards. We need to get that cash out to NHS boards as quickly as possible. We must allocate funds to NHS boards to allow them to progress with local developments. We are increasing allocations at more than the basic rate of inflation to allow NHS boards to address local priorities.

As the minister said, we must then consider how we will fund national key priorities. The decision-making process is about striking a balance between centrally-funded national priorities and allowing NHS boards to address local issues and fund the cost of maintaining their existing levels of service.

On evidence, as we develop national policies we take into account clinical evidence about different forms of treatment and that sets the direction for services such as cancer treatment. As we allocate development funding, that determines the rate of change towards the new provision of service.

I want to pursue the point about getting right the balance between national and local priorities. Obviously only one—cancer—of the three national priorities is mentioned in the five priorities on which money is being spent. There is no mention of coronary care, stroke treatment or mental health.

In my area, the local primary care trust has been asked to find £600,000 of savings from mental health services this year. It seems strange to make mental health a national priority at the same time as mental health services are being cut back locally. Why is that happening?

Historically there has been an issue about mental health not being given the same priority as the other areas to which John McAllion referred. NHS health board spending on mental health has increased significantly over the past two or three years. Last year there was an increase of about 7 per cent in NHS spending on mental health. We are moving in the right direction. The issue that the member raises is one that we will consider as part of the new performance assessment framework.

Having moved in the right direction, spending on mental health in Tayside is now moving back the other way.

Mr McAllion is giving the example of only one health board.

I live and work in Tayside and represent a constituency there, so what is spent there is important to me.

The importance that is attached to mental health in Tayside will be considered when Tayside is assessed under the performance assessment framework. We are mindful of the issue that the member raises and recently we have taken a considerable number of new initiatives on mental health. Our determination to make it a real priority is firm. The money that is being spent reflects that.

Should the new spending that has been allocated across the country be aligned in some way with the national priorities?

It certainly should.

The problem is that that is not happening. The money is not aligned with the priorities of coronary care, stroke treatment and mental health.

The member has cited the example of Tayside Health Board. However, a great deal of activity has gone on in relation to coronary heart disease. There has been a task force report. The first Clinical Standards Board for Scotland standards were issued two weeks ago; I will refer to those again in response to questions about the performance assessment framework. That is evidence of a determination to have high standards throughout the country for the treatment of coronary heart disease. The general strategy for coronary heart disease will be launched next year.

Much is happening in relation to both CHD and mental health. The way in which they are prioritised and the money that is spent on them will be considered as part of the performance assessment framework.

John McAllion mentioned the reduction in spending on mental health in Tayside. Although mental health is one of the Executive's top three clinical priorities, the recent publication of the Scottish community care statistics confirmed that local authorities have reduced by £8 million spending on adult mental health in 2000 compared with 1997. You call mental health a clinical priority, but it is not recognised as such by local authorities throughout Scotland. The statistics do not confirm that it is a clinical priority.

Some spending on mental health comes from local authorities, but the bulk of it still comes from the NHS. As I said, NHS spending on mental health has recently increased significantly. Some mental health spending comes through the mental illness specific grant, which has also been increased recently. Two years ago, the committee made a recommendation on that, which the Executive took up. However, I accept that in some local authorities there are problems relating to spending on mental health.

I have a specific question relating to the priorities. I know that the £30 million that has been made available over three years—£6 million, followed by £12 million, followed by £12 million—has been welcomed as a good start. Can the minister guarantee that that money will get to the local health care co-operatives? There are already disturbing reports from at least two health boards that the money either is not being used easily by LHCCs or, in one case, is being used to prop up a deficit.

I would welcome being given information about those cases after the meeting, if that is what is happening. We have been very clear that NHS boards must feed through the new money to LHCCs. As Susan Deacon's letter to the committee indicates, we are flagging up the needs of specific groups. More generally, greater access to primary care is the priority that is being emphasised. In practice, the money will probably be spent on additional staff, to diversify the primary care teams in LHCCs.

We require each NHS board to give us a detailed statement of how the additional funding for primary care has been spent. We expect to see in those returns a demonstration that LHCCs have figured as the key players in the decision-making process locally. Spending of the additional money is being monitored nationally.

The east end of Glasgow is in a position that is similar to that in Dundee, as described by John McAllion. The east end of Glasgow has the highest incidence of mental health problems in the city, yet there have been cutbacks; for example, in Auchinlee day hospital, which is a modern hospital. I add that as a point of information, because mental health was supposed to be one of the Executive's top priorities.

Members can give various local examples and I am interested in them all. However, I do not know the details of that example, so I cannot comment. Sometimes, there are issues about money being diverted. At other times money might be being spent differently in the same area. However, I do not know what the case is in Dorothy-Grace Elder's example.

Dorothy-Grace Elder can write to the minister with more information and enter into discussion on that matter.

The situation has been going on for a while. I gave that example as a point of information to add to what John McAllion and other members said.

I turn to the reply to question 2 in the letter from the Executive, about the end-of-financial-year underspends. We accept the point that that does not relate to 2002-3 and beyond, but that information has raised other questions. We want clarification on a particular issue. The helpful table shows that £135 million was underspent and there is a description of how £90 million of that was distributed. However, that begs a question: what happened to the other £45 million? Can you outline what it was used for?

I will flag up one issue and John Aldridge will, perhaps, flag up others.

As you know, we are discussing fees for care homes with Scottish Care and others. Indeed, Shona Robison asked me several questions about that matter during the passage of the Regulation of Care (Scotland) Bill. As part of our commitment to sorting that difficulty we put up £18 million to go at least some way toward meeting the cost of whatever settlement is arrived at. That is one item of spending that I am sure members of the committee will welcome.

The other general point is that the underspends that sit in health boards and trusts remain with them to be spent later. As members know, that is a much better arrangement than that which pertained in the past.

Those are two distinct areas that cover some of Shona Robison's question. I do not know whether John Aldridge wants to add anything.

I can add a little, if members will find that helpful.

The £90 million is the resources that were distributed to area health boards. In addition, some resources went to help special health boards with capital slippage. That amount was not large—it was about £7 million. Because the clinical negligence and other risks indemnity scheme that we run—CNORIS—operates as a fund and pays out only for the claims that come in in a year, there was more in the fund at the end of last year than was needed, so that was carried forward to this year as well.

Those are the main items that were funded, and they include the care home settlement that Mr Chisholm mentioned.

I suppose the other point to make, which I know committee members are aware of, is that the underspend figure was more than £135 million, because we gained through the redistribution across the Executive. We actually had £159 million from the end-year flexibility settlement.

You provided a table that details the underspend and breaks it down into—I think—seven general headings, which is helpful. Is it possible to break down the underspend to a level beneath those headings? For example, we know that health boards underspent to the tune of £41.7 million. Is information available about the areas in which that underspend occurred? For example, I have heard that £10 million of that underspend was money that had been given to health boards to help with the problem of bedblocking. I think that most people would be confused about why health boards underspent, given the seemingly intractable problem of bedblocking.

My general question, however, is whether we can break the underspend down further to see where health boards, for example, are not spending all their allocated funds.

I will ask Trevor Jones to deal with the point about health boards. An example about the minor underspends—which is, in fact, the largest item of all—has been given. The underspend is quite typical; it might be that the money for new initiatives such as demonstration projects is not being spent as quickly as was expected, although the same overall sum of money will still be spent on them.

My only other general remark is to point out that there is some capital slippage. That has always been the case, as we know. There is nothing unusual about it. I ask Trevor Jones to give some detail in response to the question about health boards.

The first thing to bear in mind is the level of the underspend, which is just over 2 per cent of the budget. Overall, that is not a huge amount for managing such an organisation. The second point relates to what the minister has just said. Generally, the underspend is committed to new developments. If, however, a member of staff is not appointed on 1 April in a given year, money needs to be carried forward into the new financial year so that the member of staff can be fully funded. The health boards are generally fully committed. We are dealing with non-recurrent underspending, which is brought about because of delays in recruiting staff and in implementing capital schemes.

I do not have more detail on underspending with me, but we could get the breakdown of the figure from NHS boards and details of the commitments against that sum. If it would be helpful, we could supply that information to the committee later.

It might be worth the small group of officials and committee members discussing what information on the underspend might be useful. The minister's letter states:

"The 2000-01 underspend has not affected planned progress towards targets."

Are you sure that that is the case, minister?

If I may come in on that point, convener, I raised the example of the money that is allocated for bedblocking. I have heard it said that that money formed part of the underspend. Is that the case? It alarms me that such a huge problem is being dealt with using money that, although it has been given to health boards and health trusts, is not finding its way to dealing with the problem.

I would be very surprised if that were the case, although John might be able to provide more detail.

There was a final amount; money had been issued earlier to help with bedblocking in the last financial year, and it was all committed and spent. Very late in the financial year, £10 million was issued, which had become available from underspends elsewhere in the programme. That money was released to local authorities through the health boards to deal with bedblocking. I stress that that was late in the last financial year, and authorities were not able to spend all the money in that year. As Trevor Jones said, the money was already committed and the plans for how the money was to be used to help with bedblocking were in place. It was not all spent by 31 March, however.

A great deal of discussion has taken place about the performance assessment framework, particularly with regard to how it is failing the accountability process in certain areas of Scotland. The Minister for Health and Community Care has provided us with her views about how that can be linked to the work of the Clinical Standards Board for Scotland and so on. However, there is nothing in her response that links the performance assessment framework to public accountability in such a way that individuals can question or influence it. Can you provide the committee with any more information on that?

In general, the performance assessment framework is an exciting and important development, and performance assessment involves a far broader range of areas than was the case in the past. The main areas that will be covered are these: first, health improvement and the reduction of inequalities; secondly, fair access to health care services; thirdly, clinical governance and the quality and effectiveness of health care; fourthly—and crucially—patients' experience, including their experiences of service quality; fifthly, staff governance; and sixthly, organisational and financial performance and efficiency.

Performance assessment will be public, in the sense that the letter that we send to the NHS board following the assessment will be a public document. We are also asking boards to produce factual information about the assessment in their annual reports.

That information will be generally available and if boards are failing in some areas, that will become broadly known. This is a big step forward and I would be interested in hearing of the ways in which people think that that can be developed. We are in the early stages of the process, starting with the inception of the new NHS boards this month.

Obviously, people who have a problem with the old process want to influence the process. I therefore declare an interest. To date, the system has operated like a secret society in that the organisation advises the centre of how it thinks it has complied with the instructions. How can we influence that at a local level? You talked about the involvement of patients, but how are you going to ensure that the information that you receive is true and accurate and has involved patients and staff outwith the local delivery area? Without those elements, we will not be sure that the information is robust.

We are strongly committed to patient and public involvement. The department will shortly produce a paper on that matter. Equally, we are strongly committed to staff involvement, which is demonstrated by the composition of the new NHS board and the various clinical committees. As part of the performance assessment framework, we will be examining the extent to which the clinical committees have been consulted and involved by the NHS board in its decision-making processes. You are asking whether the NHS boards will be able to pull the wool over our eyes.

As they have done for many years.

We will make sure that that does not happen. Trevor Jones may wish to speak in more detail about that.

We are bringing in a new accountability review process between the department and the boards. Those involved in the review will, in theory, meet annually but they might meet more often to deal with problems with certain boards. We will have before us a range of hard data on the areas that the minister has talked about. National data will be collected to support all areas. That will be hard, published data that we will collect rather than data that are submitted by the NHS boards. We will also have reports from key stakeholders, the Clinical Standards Board, the Mental Welfare Commission and the staff partnership forum that will act as external views. Based on that information, we will have a structured discussion with the NHS board about its performance. Whereas in the past that meeting would have concentrated on financial performance, it will now deal with all of the core business. An action plan will be agreed at that meeting and it will be sent out in a public letter to the NHS board.

We will expect the annual reports of NHS boards to use the data set to show how they are serving their public. That will result in a much more balanced annual report that will not simply concentrate on what is going well. It will enable us to examine relative performance across Scotland.

I welcome your saying that that will be a public document, but we have found that it has taken six months for such documents to become available to the public and their elected representatives. What is the time scale for the publication of the document?

We have not yet set a formal time scale, but I would not expect it to take six months. I would expect the letter to be produced within a couple of weeks of the meeting. I would also expect it to appear at the next public meeting of the NHS board.

I wait with interest to see that happening.

I would like to continue the theme of the secret society.

In response to our questions about the determinants of the size of the health care budget, the minister said that data that are already in the public domain were used, such as activity costs and outcomes and an assessment of pressures. That raises the question of how you define a pressure. For example, on the news this morning there was a story about the rise in the incidence of type 2 diabetes. Would that be included as a pressure? Would evidence of unmet need for health care or 10 per cent of hospital beds being taken up by people with hospital-acquired infections be included as pressures? How do you decide or measure what is a pressure on the NHS?

There are two ways of looking at this. I thought that your question in the letter was about health in relation to other parts of Scottish Executive spending—that is one area that must be considered across the Executive, particularly at each spending review. Perhaps you are also touching on the subject that was mentioned before, which is the relative priorities within the health budget once the overall budget has been allocated.

I am asking about the size of the budget given the pressures and how you measure the pressures and the priorities within that budget.

In a way, the care development group was part of the process. It considered spending in community care. The process is not terribly dissimilar to that for the health budget. For example, one of the main things that the care development group examined was demography, which is a fundamental factor that we must consider as we examine the needs of the health budget over the coming years. We must consider health trends—an increasing number of elderly people is a significant factor for health budgets. That is a general area of which we must be mindful.

Trends in illness and disease are also taken into account in planning. It is quite difficult to factor in disease trends in the long term. We hope that our health improvement measures will make a big difference, but we cannot predict that with absolute certainty. We have to keep track of the trends in diseases and illnesses as well. It is a fairly complicated process. We have to keep our eye on several balls at once.

Given the huge and increasing incidence of diabetes, which can lead to heart disease and so on, are you not concerned that at Raigmore hospital a first-time diagnosed diabetic would have to wait 11 months to see a consultant? There is a feeling that many illnesses have fallen off the agenda. Are you not concerned about increases in waiting lists and waiting times and the fact that more than 10 per cent of beds are taken up with hospital-acquired infections? I would have thought that such matters would be a top priority in order to utilise the beds and ensure that more people are cared for.

We have taken several steps in relation to hospital-acquired infections. We are determined to deal with that particular issue. The comment on diabetes is absolutely true and diabetes is what features in the news today. From week to week, we will read about different disease profiles—one illness may be increasing and another may be in decline. We have to keep our eye on those details.

The other central factor is staff. I am sure that members will not forget that about 70 per cent of the health budget is allocated to staff costs. Clearly we have to be mindful of the number of staff that are required. A high level group led by Professor Temple is considering work force planning and will make a preliminary report before Christmas. We must consider the different staff positions that are required as well as wage demands and other issues relating to staff development that have arisen recently. That is a major part of the calculation of the health budget.

Are you saying that it is very difficult to change priorities in the health budget because staff costs take up so much of it? Are you saying that, should diabetes become the primary concern in Scotland, it would be very difficult to change the current set-up in the NHS to deal with that urgent need?

I am sure that that is not the case. We have flagged up three clinical priorities, one of which is heart disease—where there is considerable overlap with diabetes—but those could change over time. As members know, cancer and coronary heart disease are now priorities, whereas 50 years ago the priorities would have been various infectious diseases.

You were right to refer to the vital role of staff. I hope that when you shift the waiting list for diabetes and many other conditions you will take into consideration the shortage of medical secretaries in Scotland, which is due largely to the low wages that are paid to these very highly skilled people. Can you assure us that you wish to increase the number of medical secretaries and to fill the vacancies that exist? That is one of the reasons for the bottlenecks that appear in some specialties.

It is clear that there are issues relating to particular staff positions. Over the summer, medical secretaries have been in the news quite a lot and I am sure that we are all pleased that an agreement about their position has been reached in all trusts. Later, the committee will hear from representatives of Unison, which was involved in the negotiations with trusts that led to that agreement. We now have a way forward for the important position that the member mentioned.

The general issue that Dorothy-Grace Elder raises concerns us all. We may be straying slightly from the budget, but as staff costs are such a phenomenally large part of the budget it is important that we consider problems of recruitment and retention. Do you feel that, because of national pay bargaining and so on, you are in a financial straitjacket that prevents you from giving people extra incentives that would encourage them to take up positions? We can all see that there is a shortage of, for example, consultants and medical secretaries. Do you feel that you have sufficient powers to offer people the inducements that would attract them into the health service? We all know that there are problems of recruitment and retention.

We are mindful of those issues. As members know, in three weeks' time we will hold a convention at which the full range of recruitment and retention issues relating to nursing will be considered. Nearly all the powers that can be used to deal with problems are devolved, but most of the unions are happy that pay bargaining should continue to be at UK level. We agree with them. Others may take a different view on that, but that tends to be the view that most people take. Theoretically, the position could change, but at the moment there is no great demand for one. We are still within the UK pay framework, but there are many initiatives that we can take. Earlier today the nurse bursaries were mentioned. They are not irrelevant to the issue of recruitment. Various other suggestions have been made with reference to nurses and other parts of the work force. We have some flexibility on those matters.

I would like to pursue that point and to raise work force planning. We know that there is discussion with colleges about medical and nursing cover, but we are now experiencing difficulties in other areas, such as radiology. There does not seem to be a commitment to considering the long-term objective. If we are in a three-year financial process, we should at least be in a three-year work force planning process that allows us to anticipate the future needs of the service. Planning in the health service is very poor outside what we term the sexy services—nurses and doctors. We do not tell people that the NHS includes pharmacists, domestics, catering and radiology. This committee has touched on that issue in the past, but we have never seen the long-term work force planning that we believe would be beneficial.

I assure Margaret Jamieson that we are considering work force planning, and not just within a three-year time scale. I referred to Professor Temple's group, which is considering the situation in a range of different positions, including radiographers, to whom you referred. Beyond that, there are the activities of the agenda for change—a UK agenda in which we are very much involved. It will include consideration of a range of work force issues, including pay. Work force planning is central to that. It is a major issue for us—the care development group gave a great deal of attention to planning in the social care work force.

I want to continue with the theme of pressures on the service. The deficits will be dealt with for the most part by end-of-year spending. The minister mentioned demographic pressures. What point have we reached with the implementation of current working time directives and with the reductions in junior doctors' hours? I welcome the fact that there has been a 90 per cent achievement of contract levels in year one, but people work as junior doctors for six or seven years. I suppose that I should declare an interest—I have a son who has been a junior doctor for about five years.

Another pressure on the service is the introduction of new drugs and the problems associated with postcode prescribing. In my constituency there are waiting lists for drugs such as cognitive enhancers. People with limited incomes are being forced to pay money for drugs because the deterioration in their condition is such that they cannot wait for the health service to produce them.

We must also consider care home costs. The minister was right to say that there is an interim settlement, but that is being funded out of EYF. Next year we will be faced with the same pressures—multiplied, I suspect—which will have to be dealt with out of revenue funding.

If this committee is to understand the budget, it must understand the collective view from the centre on all those pressures. If it does not, we will compound a situation in which, although it looks as if substantial new money is going into the service and everyone expects improvement, in reality we are swimming hard against the current. Because we are faced by pressures that continue year on year and to which we can see no end, the new money will not produce any benefit.

Margaret Jamieson mentioned the work force. In 1999 there was an 11 per cent shortage of radiology consultants, but this year the shortage was 12.5 per cent. The situation is not getting better; it is getting worse. There are also problems with radiography. I do not know what the situation is elsewhere, but in my constituency waiting times for almost all procedures are increasing massively. That means that there is a perception that care is getting worse. How much of the new money for next year will be used to deal with the pressures that I have described and to get rid of some of the inequities in the current system?

You have raised a number of issues. John Aldridge may be able to provide members with more detail, but I can indicate that we are at a fairly advanced stage with implementation of the working time directive, which has been a cost pressure. The same applies to the situation with junior doctors. The money to deal with that is now in the system, although there is still some work to be done.

Richard Simpson mentioned new drugs. A story broke in the news last night. We have been in discussions with the Department of Health about that this morning. Richard Simpson and other members will know that a great deal of activity is taking place on that front in the Health Technology Board for Scotland—which was also in the news recently—and in the Scottish drugs consortium, through which health boards are trying to deal with the uneven availability of drugs. I am sure that the issue of new drugs will be raised in the members' business debate on dementia this evening, to which I will reply.

We have put a significant sum into dealing with care home costs. It is difficult to say any more in detail about that until we receive the report of the group that is working on it, which is chaired by Owen Clarke. There will have to be discussions with the Convention of Scottish Local Authorities about that when we receive the report. That issue was flagged up by the care development group as something that must be addressed when we are dealing with long-term care.

You asked about staff. Additional funds are one part of that, but they are not the whole story. We will have to consider new ways of working as well. I am sure that Richard Simpson will welcome the moves to ensure that staff work more flexibly in primary care. That is one of the ways forward that we had in mind when we invested the new money for local health care co-operatives this year. I am sure that most people in primary care have taken that on board.

The need to arrive at better ways of organising services and to set clear priorities for service development does not take away from the fact that more money will be available for that area.

I think that Richard Simpson might have wanted to declare an interest.

Yes. I should declare that I am the director of a care home group in England. However, it is not affected by any of these lovely increases.

As we have come to expect from the budget process, we have a fairly large amount of data on finance and a smaller amount on activity. Over the couple of years in which we have been scrutinising the budget processes, we have not had a lot of data on patient outcomes.

In the health board in my constituency, huge amounts of money have been ploughed in to addressing waiting lists and waiting times, but it is difficult to quantify precisely what improvements have been made. Minister, if you were challenged on the budget report, would you be able to quantify the improvements that have been made in relation to the amount of money that is being put in? Would it be possible to show what improvement has been brought about year on year by the money that is being put into the service?

We are focused on that. Everything we want to do in health policy should result in better outcomes and a better patient experience. It would be reasonable to say that we should not expect the budget report to carry everything. There are many ways in which the information that you are talking about could be presented—that could be raised by the committee in any discussions with officials about improving the budget report. The Clinical Standards Board does work of great significance in terms of better clinical outcomes for patients. Two weeks ago, it published detailed information about every NHS board area in Scotland and the treatments that are available for heart disease. It will be able to do the same sort of work on other clinical areas, starting with the priority areas.

Patient experience goes beyond clinical outcomes and is an area that we want to focus on in the forthcoming paper on patient and public involvement. Feedback from patients is crucial in terms of improving people's experience of the health service. There are many ways in which we can capture that. I am quite open to more such work being done in the budget document, but I think that a lot of it is probably best done elsewhere.

I accept that. Perhaps the budget document is not the best place to go into great detail about certain subjects, but I am sure you accept that patients might want to know how long it will take to be treated for a certain disease, what kind of treatment they should expect and how that compares with what happens elsewhere. We have a good news story to tell but perhaps we are not telling it often enough. I accept what you said about the report of the Clinical Standards Board but I think that we should highlight such good news stories in another way. I would like an assurance that you believe that you will be able to quantify specifically what improvements are being made to patient outcomes from the money that is being put in.

I do not disagree with you and I think that we should explore whether the issues that you are talking about can be covered in this document. Another way of doing that would be to conduct opinion surveys. It is worth repeating that the MORI survey that we conducted recently indicated that eight out of 10 people were satisfied with their experience of the health service. That in no way leads me to complacency but it is definitely worth remembering while we are attempting to address the problems that we hear about.

We need to capture patients' experiences of the health service in many ways. We will address that issue in our forthcoming paper. We are committed to that idea and are interested in finding out whether that experience can be captured by the budget document as well.

In the past couple of years, the committee has criticised some of the targets that are set out in the budget document and questioned whether they are achievable, tangible targets that people can identify with. I know that the targets are selected from the Scottish Executive's programme for government, but we are concerned about the vagueness of some of them, for example the minister's promise, in her letter, to put more money into the development of local health care co-operatives. Do you agree that some of the targets need to be firmed up and that much more detail is needed? We need to see how the targets can be achieved if we are to be convinced that they are doable.

I am completely open to discussing targets. As you said, some of the targets are in our programme for government and I am sure that MSPs will expect us to keep our minds on those ones in particular while thinking of new ones. It is important to have targets and to monitor progress towards them. As I said, if members think that the targets should be more detailed, I am prepared to discuss that.

I accept what you are saying, but, with respect, we have heard that promise in previous years and the level of detail does not seem to have improved this year. What mechanisms will you put in place to ensure that it improves next year?

The health plan contains more than 250 detailed actions. Most of those actions are being implemented and some have been achieved. That was a fairly specific set of commitments, so I suppose that, instead of simply welcoming your comments, I should ask whether you have an example of what you mean. That would allow me to respond in a more concrete way. I do not want to be too defensive. We have set out targets in the programme for government and there are many targets in the health plan, which received a healthy welcome.

I gave you an example already. The minister promised, in her letter, to put more money into the development of LHCCs. How will LHCCs be developed? What are you going to do to increase their involvement? That is the kind of thing I am talking about: targets are mentioned, but the way in which they will be achieved is not.

As I said, we will want a detailed statement about how the money that is being made available to LHCCs is being spent. We are not forgetting about the money that we are investing; we are monitoring the way in which it is spent and ensuring that it is spent on the objectives for which it was distributed in the first place. That is part of the general increased amount of performance assessment that is being done. There is a real step change in that this year. You should be assured that we are in tune with what you are suggesting.

The committee has said many times that it is concerned about patient outcomes. There is a general feeling that, although we have data about people attending hospital and data about people dying, we do not have data about whether someone who has gone to the hospital with back pain still has back pain when they leave the hospital. We all want further development in the linking of the budget to the 250 targets in the health plan.

With reference to the specific issue of primary care and the health plan targets, I should mention the commitment to ensuring that there is access to a primary care practitioner within 48 hours. That is perhaps more specific than my previous answer.

This is the third year that we have asked for some sort of measurement of outcomes. We are constantly being told that more money is being put into the health service, but, as other members have said, it is difficult to measure outcomes.

The Executive's statistics tell us that, from 1997 to 2000, the number of clients who were seen by health visitors fell by 49,800, while the number of clients who were seen by district nurses fell by 12,200. You say that eight out of 10 people are satisfied with the health service, but I cannot see how they can be satisfied when health care is being reduced by such amounts. Those are phenomenal and frightening figures, given the emphasis on care in the community and the increase in the number of elderly people. Are you satisfied that your money is being spent wisely?

I do not recognise the figure that you cite in relation to health visitors. That would have to be looked at in the round with regard to the number of people who were visiting people at home. Also, the figure might be accounted for by the fact that greater use was made of health clinic facilities rather than home visiting.

I do not have the table that you are looking at, but it is important to consider all the people who are involved in delivering care. There might be a decline in the number of clients who were seen by health visitors, but that might be accompanied by a corresponding increase in the number of clients who were seen by other health or social care workers.

Our problem is that we cannot measure outcomes. The community care statistics tell us that, from 1997 to 2000, the number of clients who were seen by health visitors fell by 49,800. The statistics do not say that those 49,800 clients were seen by other people. How can we say that those clients are receiving better care?

That is our challenge. You sit there and say, "They might be going here, there or everywhere." We do not know that. All we know is that, according to the statistics, health visitors and district nurses see thousands fewer people than they saw in 1997. How do we measure care when people may have been treated elsewhere? We do not know where those people have gone.

You flag up a danger. We cannot consider only one part of the statistics; we must consider them in the round. You flagged up figures on health visitors, but district nurses will have a different line in the budget. The figures are in front of you, so you have a slight advantage over me, but I suspect that the district nurse figures are different from those on health visitors.

In one year—from 1999 to 2000—district nurses saw 7,300 fewer clients. Are those 7,300 people healthier people who do not need to see a district nurse, or have they lost out? We need to know that to have an informed input to the budget. We have scraped around for information for three years. We cannot make the informed judgments that we would like to make, because we cannot obtain the information from your department.

That is information that you are using to good effect.

Thank you.

The information is publicly available. The only caveat that I give is that we must consider care in the round and the balance of people who are being visited at home, going to a health clinic and receiving other care at home. The general issue of home care hours has been flagged up recently, but the trend is being reversed because of the extra money for home care in the past couple of years. We must consider the spectrum of care for those people, rather than point out one line.

I will respectfully ask the minister about home care. More than 9,000 fewer people now receive home care. All the statistics show that people receive less care at home. Will the minister say where I should go for the information that he says is available? How do I measure health care in the community?

We must be careful when we examine home care figures, because people often ask for local authority home care figures and forget that much home care is delivered privately. People may arrange such care themselves, or local authorities may commission it from private providers. We must consider the whole picture of home care.

There was a trend, but it did not start in 1997. That trend is being reversed. The most significant injection of money into home care services is being made with the increase from the £100 million that was announced one year ago in October 2000, which is coming on stream. More is to come with the second £100 million for personal care, which will cover the development of services in the community.

The trend is being reversed. We have a collection of statistics, which help to build up a picture, but we must try to capture people's experiences and their views of the services that they receive. We did much of that work in the care development group. We know that we must address many problems and difficulties, but the home care trend has been reversed and such provision is increasing.

Not according to the figures.

As you have the figures and I do not, all that I can do is undertake to write to you on district nurses and health visitors—

And home care.

I will write with a more detailed statement about the issues. My experience is that health visitor hours have decreased, but hours for others, such as district nurses, have increased.

The figures have not increased in the recent statistics that I have.

Okay. I will examine the most up-to-date figures.

I have the statistics for 2000.

The minister returned to talking about his millions, but I am talking about people. Will the minister start talking about outcomes rather than millions?

I ask Mary Scanlon to take on board the minister's undertaking to investigate the matter and send us a response.

Another point arises from Mary Scanlon's comments. In the wake of the Community Care (Scotland) Bill and the injection of investment, even more people will have different ways of accessing care, because of factors such as direct payments and the social work and health sectors working together with pooled budgets. The question is whether scrutiny and accountability will become even more difficult for us than they are at the moment. I would appreciate a written response to that question, rather than taking any more time at this point.

Nicola Sturgeon has a further point.

No. It has been answered.

We will clarify the points in this area that we want answers for and write to you for clarification.

For the past two years, the committee has been critical of the information in the budget about private finance initiative projects. In our most recent letter to the minister, we pointed out that that information was inadequate, because only capital costs were provided and there was no information about the annual revenue payments that health trusts are required to make under PFI contracts.

In her written reply to the committee, the minister addressed that criticism by saying that copies of the business cases for all PFI projects valued at more than £10 million have been placed in the Scottish Parliament information centre and that those business cases provide further information about the annual payments. First, when were those business cases placed in SPICe? Secondly, can you confirm that the business cases will show the Lothian and Lanarkshire health trusts' annual revenue payments for their PFI hospitals, the number of years for which they will have to make those payments and the capital costs, so that the net revenue costs to the NHS of PFI projects can be worked out?

Yes. I give an undertaking on that. The business cases were not put into SPICe recently, but when they became publicly available. The main point of fiscal interest is the annual payments, which are set out clearly in those documents—as the minister's letter says—for any projects that are valued at more than £10 million. It is easy to find out that information. As you indicated, that information is about annual revenue payments, whereas the budget document indicates the overall capital value of the projects.

Do the business cases indicate the number of years for which the annual payments will have to be made?

Yes.

How easy will it be to retrieve that information from those documents? Would you require to be a health economist to find exactly where that information is?

No. You would not require to be that.

Why has that information been placed—some might say buried—in SPICe, rather than in the Scottish budget document? For each of the PFI projects that is listed, it would be fairly easy to include a footnote that said what a trust's annual payment was and for how many years it had to be paid. Why cannot that be done?

John Aldridge will take that point.

I dare say that that could be done.

If it can be done, why not do it?

Our view was that putting the business cases for projects over £10 million in SPICe, rather than putting them in the budget document, would mean that the information would be readily available to MSPs at an earlier stage.

I suppose that there were two reasons for not putting that information in the budget document. One reason was that we thought that the information was already readily available in SPICe. The other reason was that it would take up a lot of extra space to provide all the information for each project. The committee previously raised the issue of the need to strike a balance in the budget document between putting more information in, which might be available elsewhere, and—

Only 10 projects are listed in the budget document. Of those, only six have budgets of more than £10 million; four have budgets of between £3 million and £10 million. That does not take up a lot of space. You could easily put footnotes at the bottom of the page, which would provide the information without taking up huge amounts of space. Why cannot I find out, for example, about the Carseview acute psychiatric unit at Ninewells hospital in Dundee, which has a budget of £10 million? You do not provide information about the annual payments that are made by Tayside University Hospitals NHS Trust for that facility.

Nobody is trying to hide that information, Mr McAllion.

Well, it has been hard to get in the past. When I have asked about it, I have been told that it is commercially confidential.

Why is that information not commercially confidential above £10 million?

I am sorry, but are you talking about the above £10 million?

It has been difficult to find out the true costs of PFI projects, because the information has not been readily available. By the way, it is news to most members of the committee that those documents have been in SPICe for many months. When were they first put there?

It varied from project to project. The requirement is that they should be lodged once the contract has been signed and the project is under way. That did not happen from the start. It is only more recently that we have introduced that requirement.

What does "more recently" mean?

I think that the requirement was introduced about a year or so ago.

Have the documents been in SPICe for a year?

They should have been available since then. Some may have taken a little while, but when we found any that were not lodged there we chased them up.

My first question follows on from what John McAllion said. Will you put the business cases for all the PFI projects in SPICe? I do not understand why we can see the business case for a project in south Glasgow, whose capital value is £11 million, while the business cases for projects with capital values of £10 million or £9.6 million are to be kept hidden from us. Will you undertake today that the business cases for all PFI projects—there are not many of them—will be placed in SPICe?

My second question relates to the detail that we will find in the PFI business cases that have already been placed in SPICe. For example, will the business case for the new Edinburgh royal infirmary show any increases in the revenue cost from the point at which the business case was settled? It was reported at the weekend that the annual revenue payments for the Edinburgh royal infirmary will be some £1.9 million more than anticipated, which amounts to £60 million over the period of the contract. It has been reported that that will lead to a deficit in the trust. Will we find that information in the business case, or has it come to light only since the business case was written, in which case we would be unable to access it even from the documentation that you have put in SPICe?

I shall let John Aldridge deal with some of the detail. Obviously, there have been quite a few figures flying about over the weekend in relation to the new Edinburgh royal infirmary. Some of those figures are quite misleading, particularly the figure of £38 million, which is quite mysterious and does not seem to bear any relation to—

What about the £1.9 million a year?

I was going to say that £1.9 million is the one figure that is correct. However, that is basically the uplift for inflation and it has not come as any surprise to anybody that, even in the brave new world of low inflation that we have had since the Labour Government of 1997, we still have some inflation. That is what the £1.9 million represents. John Aldridge may want to deal in more detail with that point, and also with the question about projects under £10 million.

I shall start by dealing with the projects under £10 million. Table 5.20 in the budget document shows the capital value of those projects worth £3 million and above. The £10 million cut-off point for lodging business cases in SPICe was, I concede, fairly arbitrary. The figure was chosen simply to ensure that the largest and most important projects were there. We could reduce the limit, but I would be reluctant to undertake to require business cases for every PFI project to be placed in SPICe. A large number of very low-value projects are going ahead.

Surely it is in the public interest that that information is available. With the greatest respect, I am not sure that it is for you to make an arbitrary decision on which PFI contracts are open to scrutiny by elected members and which are not.

The fact that business cases are not in SPICe does not mean that they are not available. Business cases are available from trusts for any member of the public or anybody else who wants to get them. If members want every business case of every PFI project to be lodged in SPICe, that could no doubt be done. There would be a very large number of business cases for relatively small projects.

Perhaps you could clarify for us the numbers that are involved. We could make a decision based on that information.

You said that the decision to lodge business cases only for projects that are worth more than £10 million was arbitrary. You also said that many projects were on a small scale, which may well be true. However, I use East Ayrshire community hospital in my health board area as an example of the fact that, irrespective of the cost, such projects are an important part of the NHS infrastructure. Nicola Sturgeon is right—we have a right to have those documents in SPICe if that is what we want. It is not correct to say that people can always get the business case from the trust. You would need a tin opener.

We have undertaken to consider that matter. We will outline in correspondence how many business cases we are talking about and take it from there.

I move on to the discussions that you are having with the health department about beta interferon. Will you clarify what the process will now be for a decision on beta interferon? Will you indicate whether you will support funding for national clinical trials, along the same lines as the Department of Health has announced?

It should be pointed out that nothing has, as yet, been announced. There was what is generally called a leak, or a trail, to the BBC news last night. We contacted the Department of Health this morning and found that no official announcement has been made.

Two processes appear to be going on. One is the process that you all know about—the work of the National Institute for Clinical Excellence. NICE has published draft conclusions, which are being consulted upon, and will come to its final conclusions in due course. The Health Technology Board for Scotland will then kick in with comments.

From what we have gathered in the past 12 hours, it appears that the Department of Health might wish to do something over and above that. However, given that no official announcement has been made and that I only heard about it on the news last night, it is difficult for me at this stage to say what we will do. However, today we will certainly be in close discussions with the Department of Health. The development appears to be very interesting and we will keep in close touch and hope to say something about it soon.

If the leak proves to be from a good source, and the Department of Health is taking that route, are you telling us that your department will actively consider the issue?

Absolutely.

I have a more general point on prescribing and the introduction of new drugs. Over a period of months and years, members of the committee have sought clarification on who is responsible and on the different bodies involved, such as the HTBS, the Scottish medicines consortium and various others. There has been some debate in the past week about the future of the HTBS. When will we get clarification on clinical governance and the decisions that are to be taken on which drugs can and cannot be prescribed in Scotland?

There are two issues there. On the first, more general, issue, the chief medical officer has been reviewing the different clinical governance bodies. It is generally accepted that, although each of those bodies does good work, there might be an issue about how many bodies there are and how they relate to one another. There will be conclusions from that review. It is always dangerous to predict when conclusions will be available, but it will be soon.

Your second point was more specific.

It was about the future of the HTBS.

The HTBS is one of the bodies that are being considered by the chief medical officer. We are considering the configuration of some of those bodies and there will be an announcement on that before too long.

The more fundamental matter is the work that the HTBS does. We are not saying that that work is not important; it has to go on, as does the related work of the Scottish medicines consortium. I am sure that everyone agrees that the work is important, but there will be developments on the precise configuration of those bodies before too long.

Will that have an impact on the drugs and therapeutics committees that are running amok in some health board areas?

You describe the issue of the drugs and therapeutics committees in an interesting way. We have tried to introduce order and consistency to those committees through the development of the Scottish medicines consortium, which is an important step forward. The consortium tends to examine new drugs that come on to the market, whereas the Health Technology Board for Scotland tends to deal with drugs that have been around for a bit longer, such as beta interferon. There is confusion about the roles of, on one hand, the drugs and therapeutics committees and the consortium and, on the other hand, the Health Technology Board for Scotland. I do not know whether that answers your question. I was distracted by your colourful phrase.

The problem is that decisions about drugs from the centre can be overturned at health board level by the drugs and therapeutics committee if it does not recommend the use of the drug.

That is what happened historically, but we expect it to happen less and less as the national groups kick in.

I do not want the problem to be merely reduced. If a drug is found centrally to be in the best interest of patients, it should be available irrespective of health board area. We are pointing out to you areas in which there is a difficulty in getting knowledge through to the point of contact with the patient and we want you to say that you will remove the problem.

We are absolutely committed to dealing with the problem of postcode prescribing. I am sure that the matter will be raised in this evening's debate in Parliament and I will give a similar response then.

You can take the committee's view into this evening's debate and into the discussions that you will have in future with the chief medical officer about the matter. Many members feel that in a country of 5 million people, which, I think, is the equivalent of the city of Birmingham, the situation flies in the face of common sense. One would not expect people in one part of Birmingham to have access to a drug and people in other parts not to have access. Frankly, it is ridiculous to continue with that situation in modern-day Scotland, which has bodies such as the HTBS that are able to consider whether drugs are medically and financially effective. There are strong feelings in the committee about postcode prescribing in Scotland.

I want to move to the perennial issue of free personal care. Given that we are discussing the budget, an important matter is yet to be resolved. The money that has been set aside from 2002 for free personal care remains some £20 million short of what the group that the minister chaired said was required to fund that commitment and everything that went with it. Negotiations with his Westminster counterparts are continuing, but the indications are that Westminster will not agree either to continue to pay attendance allowance or to transfer the money that it saves to the Scottish Executive. The First Minister said that, notwithstanding that, the money will be available in full.

Putting aside Westminster's view for one minute, will the minister say, if the Scottish Executive must find that additional £20 million, where in the projected budget that money will come from?

We have not reached the stage of giving up on our discussions with Westminster, if that is what you are suggesting. The care development group took a fairly robust line on the matter, which has been continued by the First Minister in his discussions with Westminster and in his public pronouncements about that. We are pursuing the matter vigorously and we still hope for a favourable outcome so it would be premature to say from where we will take money.

I am not sure that it would be premature. I would be appalled if you had given up on the negotiations with Westminster, because I hope that those negotiations prove to be positive.

The First Minister has said, quite rightly, that there is a plan B: if the money is not forthcoming from Westminster, it will be found from within the Scottish Executive's budget. Given that the committee is discussing that budget, we surely have a right to know where you think that that money will come from. Until we know that, a question mark remains over the funding of free personal care.

There should be no question mark over the funding, because the commitment has been given. The question is hypothetical. If no money were to come from Westminster—and I do not need to remind the committee that the money is already spent in Scotland—a decision would have to be made about that. Since the decision on the source of any additional money has not been made, I obviously cannot talk about it to the committee this morning.

Given that we are careering rapidly towards April 2002, can you indicate when the negotiations with Westminster are likely to reach a conclusion?

I cannot give a precise date on that, because we do not see an end point except when we have been successful.

This is an important point. Given that the commitment will take effect from April 2002, at what point will you decide that the negotiations are not looking hopeful and that the money will have to be found from elsewhere? When will you tell us where that money will come from?

I cannot gaze into the future and give you an answer to that question. Obviously, a certain point will have to come, but there are quite a few weeks and months to go before the beginning of April. We hope that there will be progress.

I presume that you will have contingency plans in place well before April 2002.

Clearly, we will be looking at options for that.

I thank the minister, John Aldridge and Trevor Jones for giving evidence.

We shall adjourn for a short time. I apologise to members of the public in the gallery, who must leave while the committee has a private discussion about the next item. Due to the fact that we received information at short notice last night, we had to spend more time discussing the matter in private earlier this morning than would normally be the case. The security people will bring the public back in when this private discussion is finished.

Meeting adjourned.

On resuming—