Chamber and committees

Thanks very much, Mr Middleton. I start by saying to you and to colleagues that what we seek is transformational—not marginal—change.

On the arrangements that will serve the people in the north of Scotland, my rhetorical question to you and to other MSPs is, how are current arrangements working for you just now? From the questions posed to me in chamber, the correspondence that I receive from members of the Parliament, and written parliamentary questions, I hear dissatisfaction with the status quo. That applies in the north of Scotland as it does elsewhere.

Let me be candid; change and public sector reform are not optional. We are making changes because we want to protect services in the north and elsewhere. Our national health service is our most precious service, and we need to protect it for the future, as there is rising demand. I am acutely aware of the uniqueness of different parts of Scotland, including the north, the more rural parts and our island communities.

Let me be straightforward and say that this is not about centralisation. In fact, it is the opposite. I have been very clear with my officials, the chief executives and the chairs of boards that we must not confuse a move towards removing boundaries, removing bureaucracy and a simplification of decision making and governance structures with local service delivery. I want to do more to boost fragile services in all parts of Scotland, because there is an issue of equity, despite Scotland being a relatively small country. If we want to do that, we have to make better use of our resources, and in some areas that requires us to work on a once-for-Scotland basis.

We do not need 14 different ways of doing things. We need to reduce unwarranted variation—I choose those words carefully, because this is not a one-size-fits-all approach. I hear about unwarranted variation a lot from MSPs, who, at the end of the day, represent the people that we seek to serve.

I will endeavour to continue to reassure people in all parts of Scotland that PSR is about serving all parts of Scotland.

Important foundations have been laid, but I stress that it was not guaranteed that we would land on having two strategic boards. There was an inquiry process, and any Government has to balance pace and deliverability issues. There are always other options available in such processes. Having one board was an option, but that would take longer to pursue and would require primary legislation.

I noticed in Labour’s manifesto that it supports having three health boards, but that is the only place that I have seen that suggestion—I say that with respect. That suggestion has not been made through the system or through the engagement that I have had.

We have an important platform to build on, which is the structures around what we call subnational population planning. Forgive me—we have lots of titles, language and jargon in the health service, which at times might feel impenetrable. In essence, subnational population planning was about enabling health boards to work together. For pragmatic reasons, it took an east-west approach, because there needs to be both a balance in the range of services provided and sustainability. I am not telling any tales out of class, but there are particular challenges in NHS Highland and in NHS Grampian—NHS Grampian has been escalated to stage 4. Any structure has to be sustainable. We need the breadth and depth of services if we are going to get people to work together to improve equity.

I also stress that the reform is not only about vertical co-operation; irrespective of the east-west structures, we will expect people to work in a once-for-Scotland way and across the east-west provision. I apologise for the length of that answer.

09:45

I would not necessarily describe subnational planning as a trial, and I certainly would not describe the move from subnational planning to two strategic health boards as a fait accompli.

You are absolutely right that there is some very valuable learning here. Subnational planning has taught us about the potential for co-operation, particularly around planned care. I will not repeat what I said in my opening remarks, but I referred to the progress that has been made on the longest waits. That work has taken us so far, and it has involved the subnational planning taking to heart the population health framework and being focused on co-operation as people do what they can to work together and remove boundaries. Ultimately, however, it is a voluntary arrangement.

In developing the approach further, we now need to remove some of the legal and structural boundaries between health boards. There is really important learning there, and I will have a discussion with officials about what we could share with the committee. The best example may concern orthopaedics and the work that the east and west subnational planning structures have done around understanding trajectories and how they can work together to meet the overall aim by the end of this parliamentary session, so that no one waits longer than 26 weeks for their treatment. There is definitely information that we can share.

Convener, you have given an example of unwarranted variation. We have heard about two experiences at two different health boards, which, in a country of this size, should not be the case. At the core, our reforms are about a once-for-Scotland approach and equity of treatment and access.

There will be many measures. We are not short of statistics or reporting in the health and care system—that is for sure. We release a plethora of data reports every month and, usually, several in any one week. It is important that we get the right measures.

The issue that occupies much of my time is activity. Are we using all our current capacity in NHS estates? Tracking activity levels is therefore really important.

Ultimately, waiting times are an important measure. How long are people waiting for planned care?

Another measure is progress around the national hospital flow plan, which is essentially about the movement of patients through the system. That plan includes immediate actions around the expansion of hospital at home, the roll-out of discharge without delay and tackling issues in and around corridor care. However, it is also a five-year plan.

The plan is pragmatic, action-focused and strategic in trying to get one continuous journey for patients. It looks at the interdependencies. For example, people are waiting too long in accident and emergency departments, because those become very busy, due to demand, until they become full and congested. That happens because hospital occupancy levels are high and people cannot be moved on through the hospital. Delayed discharge is part of that. When our A and E departments are congested and too full, we see an increase in ambulance handover times. That takes us back to the activity levels and performance of primary and community care as well as the issues with same-day access and the preventative metrics that we spoke about earlier.

There will be a range of overlapping discussions. In my engagement with health stakeholders when I came into post just before the summer recess, people were saying to me, “What do you want to do? Can you just tell us what you want to do?” Discussions on public sector reform can be very circular; because of those interdependencies between health, social care and local government, we can all go round in circles. I was really keen to put a stake in the ground and say, “This is where it starts.” It starts with NHS simplification, but that will not be the end of the journey.

The issues around social care most certainly do not all lie in the hands of the Government, so we have to work with our partners. Of course, there is also the broader discussion around local government.

I am happy to share this, because I am just working through the final details of what will be my programme of engagement. Obviously, other partners across Government are involved in this, but I will lead on NHS simplification and social care reform, supported by Mr McKee and the Deputy First Minister, given their interests in public sector reform and local government, as well as by the two ministers sitting next to me.

There will be lots of discussion and exploration. Nothing is off the table. There are no blank sheets, but there are no tablets of stone, either. You will have heard the First Minister say that. The endeavour to put some structure and limits around this is something that we have been talking about for a long time. Let us bring social care reform to a shared point of fruition, because social care is an essential service, and its reform is essential.

The Baird and ANCHOR facilities are much needed, and we absolutely must proceed with them. It is regrettable that there needed to be changes. I accept that they were needed for patient safety and I am not going to argue with that, but it is always regrettable when changes need to be made once construction starts. That is a source of frustration for me, and no doubt for Mr Middleton as the local MSP, but the facilities are much needed and we absolutely want to get them over the line. Again, there are oversight procedures that involve the chief operating officer, in the same way as with Queen Elizabeth university hospital, because patient safety is always paramount.