Meeting date: Tuesday, November 8, 2016
Health and Sport Committee 08 November 2016
Agenda: Section 23 Report, Recruitment and Retention, Mental Health
Section 23 Report
“NHS in Scotland 2016”
Good morning, everyone, and welcome to the 10th meeting in 2016 of the Health and Sport Committee in the Scottish Parliament’s fifth session. I ask everyone in the room to ensure that their mobile phones are silent. It is acceptable to use mobile devices for social media, but I ask people not take photographs or film proceedings.
The first item on the agenda is an evidence-taking session on the Audit Scotland report “NHS in Scotland 2016”. I welcome to the committee Shona Robison, the Cabinet Secretary for Health and Sport, and Paul Gray, who is the director general of health and social care and the chief executive of NHS Scotland.
I invite the cabinet secretary to make a brief opening statement.
Thank you very much, convener. As I made clear in my parliamentary statement last week, the Audit Scotland report has provided a balanced overview of the national health service and makes several recommendations, which we accept in full. I welcome having a further opportunity to discuss the report this morning.
Our investments and achievements are recognised in the report: funding is at a record high of close to £13 billion; staffing is at its highest-ever level; and health, patient safety and survival rates are all showing improvements. However, as I highlighted last week, to equip health and social care services for the future, we must reform as well as invest. We acknowledge the demands and pressures, which is why we will continue to drive forward our significant programme of transformational change. By the end of this year, we will set out a transformational change delivery plan for the integration of health and social care, the national clinical strategy, the public health strategy, realistic medicine, workforce recruitment, supporting population health and achieving the 2020 vision.
Audit Scotland highlights the point that we need to make a shift from relying on treating people in hospital to supporting people with better care in their own homes and communities. That is what we intend to do. Over this parliamentary session, we will increase health spending by almost £2 billion and invest an additional £500 million in primary care. That will mean that, for the first time ever, half of the health budget will be spent in the community delivering primary, community and social care. The committee will also be aware that we are investing £200 million in elective and diagnostic treatment centres to address the changing demographics of our nation over the next 20 years, particularly the likely increase in our elderly population.
It is important that we focus on outcomes for patients and that the mechanisms that we use to measure performance better reflect those outcomes. Our arrangements for a review chaired by Sir Harry Burns will ensure that our targets and performance indicators lead to the best outcomes for people who are being cared for, whether in hospital, community care or social care.
Audit Scotland is supportive of our transformational change programme. It is now important that we work together across the Parliament and with our colleagues in health boards and local government to make it happen. Through that approach of continued investment and reform, we will set the basis for delivering the 2020 vision and our longer-term strategy up to 2030. That will ensure a safe, sustainable and person-centred NHS for the people of Scotland.
The committee is aware of your proposal to present by the end of the year the plan to bring about that transformational change. The Audit Scotland report says:
“it is not clear yet what number and levels of staff will be required until further work is done on testing new models and a clearer plan is in place.”
It points out that the workforce plan that the Government has published
“is high level and does not outline the workforce requirements to deliver the 2020 Vision and the National Clinical Strategy.”
The committee recently heard from a representative of the Royal College of Midwives, who stated:
“The NHS is running a third test of its workforce planning tool for midwives. If it is having a third run to test the tool, it cannot tell me that the tool is robust.”—[Official Report, Health and Sport Committee, 1 November 2016; c 28-29.]
The Royal College of Midwives also suggested that boards had done some previous workforce planning in isolation, without getting input from professionals on the ground. What is happening now to develop the workforce plan with all those from whom we have heard evidence?
We very much want to involve all the stakeholders you mention and others in the development of both the regional and the national workforce plan. Workforce planning has been a key part of the NHS for a long time, but it has tended to be done at a board level. We have worked with boards to ensure that they land their workforce plan as accurately as possible, but we recognise that we need to take a regional and national approach to workforce planning in a way that we have not previously done. That is the new part of the approach.
However, that cannot sit in isolation, which is why the delivery plan that I have talked about this morning—and to which Audit Scotland referred—ensures that all the strands have to be brought together. We cannot look at the workforce in isolation—the workforce plan has to be overlaid by the financial plan, the national clinical strategy and realistic medicine. It is about bringing all those elements together in a coherent way that will set out for the next five, 10 or 15 years what is required to make some of these changes. For example, a key part of the workforce plan will be to ask what primary care workforce will be required to make the required shift. That is not only about GPs but about advanced nurse practitioners and allied health professionals, and I suspect that there will be some new roles. It is about bringing all that together to make sure that the workforce is there in sufficient numbers as we shift the balance of care across. That is the new part.
It is almost as much of an art as a science to get workforce planning accurate, because things change. A board may have a workforce plan that it thought was robust, but the needs of the local population may change so it can find that it needs to make changes to the workforce plan. The regional and national approach is right, because we can project as far as we can what the changing needs will be and what the workforce requirements will be, particularly in primary care.
Donald Macaskill, the chief executive of Scottish Care, told the committee that the vacancy level for social care nurses has reached 28 per cent. I appreciate what you are saying about the Government perhaps having a wider vision about which professional vacancies we need to fill. Will there be greater national direction on previously non-controlled subjects?
I think that there will need to be greater national and regional direction than there was previously. Social care is more complex because, in the case of care at home, local government is the employer, so workforce requirements across health and social care will need to be integrated through our integrated plans and the integration joint boards. It is not just about health; it is also about the social care dimension.
I know that the Royal College of Nursing has raised concerns about the nursing component in nursing homes. It has always been a difficult area to recruit to for a variety of reasons. We are keen to work with the RCN to look at whether we can enhance the career opportunities for nurses working in nursing homes by enabling them to take advantage of training opportunities and career development in the NHS. We need to look at more imaginative ways of trying to encourage nurses into the nursing home sector if we are going to stabilise that situation.
Jill Vickerman of the British Medical Association last week expressed concern about how vacancies are recorded. To understand fully what vacancies exist, would it not be more sensible to include posts that are currently being filled by locums and posts that have been advertised but are no longer being advertised? I think that Jill Vickerman made the point that if, for example, staff on a ward know that there are 10 vacancies but only three are being advertised, that will have an impact on morale. I think that a clearer system would be appreciated by all.09:45
Obviously, there has been a standardised way of recording vacancies, and I understand the point that Jill Vickerman and others have made.
It is very challenging to fill vacancies. That is not just a Scottish problem; it is very much a United Kingdom and international one in some specialties. A lot of work is going on to try to attract people to those posts, by making those posts more attractive or offering them across more than one site.
We are also looking at whether posts that are continually filled through locum or agency staff can be dealt with in a different way. In the case of agency staff, the chief nursing officer is looking at converting some agency spend into substantive posts rather than relying on agency and bank nurses. If a shift rota in a hospital continually uses a high level of agency nursing, an analysis of that might determine that it is better to convert that into substantive posts. Discussions about that are going on. It is more difficult with locum medical posts. The medical bank tries to help with short-term vacancies, but that is a bit more challenging.
We are happy to speak to Jill Vickerman and others about how we will take the matter forward in our workforce plans, and we will listen to what they have to say.
Good morning. My question is a supplementary to Alison Johnstone’s question on workforce planning. What impact has Brexit had on the deliberations and the work that is under way on workforce planning? In particular, given the UK Government’s failure to assure the status of European Union nationals and, indeed, its description of EU nationals as a “bargaining chip”, are any contingencies being factored into workforce planning for a hard Brexit?
Those issues will be looked at in more detail in this afternoon’s debate. There are concerns about the impact on our medical and nursing workforce in particular. I think that around 6.8 per cent of doctors currently have EU status, and there would be a significant dent in the workforce if we were not able to retain those doctors to work in Scotland. We want them to continue to work here as well as the nurses and the social care workforce who have come to train and work in Scotland. We very much value them.
To give reassurance to students who are already studying here, those who are about to begin their studies here and those who are applying to study here from 2017-18, we have made a commitment that they will continue to enjoy free tuition for the duration of their studies at our medical and dental schools. Unfortunately, we cannot provide assurance on their future rights to remain here to train and work. That could impact on their future career decisions when they are deciding where they want to go.
The issue is important and is part of the negotiations. We will have more to say about that later today. It is important that the key message is that we very much value the contribution that those people already make in our health and care services.
Good morning, cabinet secretary. Thank you for coming to the meeting.
The Audit Scotland report is quite uncomfortable reading for all of us who have a stake in the healthcare profession. However, the Government met one target, which related to the treatment of drug and alcohol cases, particularly at the acute end. I congratulate the Government on that, but perhaps that is a case of what it gives with one hand, it takes away with the other.
Last month, we heard from Rob McCulloch-Graham, who is the chair of the Edinburgh integration joint board, that the impact of the 22 per cent cut to alcohol and drug partnership funding in the previous Scottish Government budget would be measured out as a £1.3 million year-on-year loss to services in the drug and alcohol field in Edinburgh alone. To my mind, that is a fire sale. We will see the impact of it over not just years but decades, and not just in Edinburgh but everywhere in Scotland where drug and alcohol misuse is a problem—we have already seen a measurable rise in HIV cases in Glasgow.
I would like the cabinet secretary to share with us her reflections on the Audit Scotland report and the fact that, although we might be meeting the acute treatment targets on drug and alcohol misuse, we will be messing up the end game.
First, I will make an overall comment about the targets. It is important to say that the 31-day cancer target was missed by only 0.5 per cent. That figure represents people—about eight patients in total—and we have to strive to do better than that, but it is important to remember the context in which Audit Scotland put that missed target.
I recognise that we have a challenge on out-patients. That is why we are bringing forward a programme of additional investment in that area and, importantly, implementing a transformation programme in out-patients services. We need to better manage the out-patient capacity.
On alcohol and drug partnership funding, you will be aware that we wrote to boards to ask them to support the funding levels of ADPs. Some have done so and some have not. We will continue to work with those boards and discuss with them ways in which we can ensure that the delivery of alcohol and drug misuse outcomes—which are what is really important—continues to be as good as it is. It is important to note that many partnerships have delivered well over what they were asked to deliver and have performed extremely well, and that there has been a substantial investment in alcohol and drug misuse funding. We have also said that we need to review the priorities of ADPs and examine their performance more generally, and we might want to discuss with ADPs some changes that they could make and focus on the outcomes for the next period of time.
As I have said to the committee before, we will continue to talk to boards about ADP funding, we will continue to look at what ADPs do and we will continue to examine the outcomes and ensure that the ADPs are in a position to deliver those outcomes.
I am encouraged to hear that the issue is still very much on your radar. However, a cut of 22 per cent in the overall budget for alcohol and drug partnerships can lead only to a withdrawal of service in some areas, as we are seeing in Edinburgh. It is fine for you to go to the local health boards and the integration joint boards and tell them to make up the shortfall somehow, but it is a different matter to make that materialise. That loss of service will undoubtedly lead to a proliferation of drug and alcohol misuse and to long-term addictions going untreated, which I think will have a material impact on the treatment targets. If we see an increasing demand for acute treatment, those targets will be missed in the future. Can you explain to us the reasoning behind the original cut to the ADP budget in the previous Scottish budget?
The ADP budget was an amalgamation of health and justice funding, as I am sure that you are aware.
To give a little bit of context, I should point out that, since 2008, the Government has invested more than £630 million in tackling alcohol and drug misuse, which is a significant investment. We made clear to boards that we expect the outcomes to still be met and that they will need to ensure that that happens. We suggested that boards should maintain the level of funding through their resources and, of course, boards have been given above-inflation increases this financial year. However, regardless of how they do it, we will still require ADPs, with the support of boards, to meet their outcomes.
The review that is under way with key stakeholders is part of that. It is examining how we can support boards to do that. There may be a need to focus some of the alcohol and drug partnerships more around some of those outcomes. ADPs are very varied in what they do and how they operate, and we need to bring a bit more standardisation to that.
The bottom line is that outcomes matter. The funding is important, but it is the outcomes for that funding that are most important. We have been clear that those outcomes still require to be delivered. That may be through the level of funding that they have been allocated—and if they can do that and deliver the same outcomes by doing things in a different way we will look at that—but if not, we will require and expect boards to support the ADPs in delivering the outcomes. The outcomes still require to be delivered.
I think that everybody around the table would absolutely agree that the outcomes matter and still need to be delivered, but your answer, cabinet secretary, has the feeling of a premiership football manager telling the team to deliver the same result when three players have been sent off the pitch. What we are talking about here is a 22 per cent loss in resources. I say with respect that you did not answer my question about why the Government has felt that it was okay to withdraw that 22 per cent of funding.
We have asked boards to support that funding at the same level as they did previously. The budget was an amalgamation of health and justice resources, and we have asked boards to supplement the funding.
Outcomes are the most important thing: funding is important, but most important is what is delivered with that funding. Waiting times have been hugely reduced, with 94 per cent of people now being seen within three weeks of being referred. The national 90 per cent local delivery plan standard is being routinely met, and drug taking in the general population is falling. It is important that alcohol and drug partnerships deliver their existing outcomes, but they should also look at what the outcomes should be in the light of all of the information. As part of the review of targets and indicators more generally, what do we and ADPs think they should focus on in the coming period in the light of that shift in behaviour? There are still challenges, particularly among some of the older population, so we need to make sure that the substantial resources that are still going into drug and alcohol treatment are delivering the right things and refocusing on where the biggest problems remain in the light of that population behaviour change—which is, of course, a good thing.
We have heard several times this morning that outcomes matter. According to the Audit Scotland report there is a funding crisis, workforce problems are impacting on patient care, agency use and vacancy rates are up and seven of the eight key targets or outcomes are being missed. If outcomes matter, we have a problem. How can it be, when seven of the eight targets are being missed, that further budget reductions are being regarded as “efficiencies”?
Well, I am sure—
I am sorry. Could I direct that question to Mr Gray, first? Mr Gray is the senior official with the NHS in Scotland and is obviously, along with the cabinet secretary, accountable for it, which is why I want to bring him in.
Efficiency savings have been delivered year on year by the NHS in Scotland. That is not a new proposition. So that I answer your question appropriately, what are you referring to specifically when you say “budget reductions”? The budget has gone up each year.
Boards they tell us that they are making very significant reductions. I do not want always to harp on about NHS Lothian, but it tells us that it has made something like £68 million of reductions this year. If it is already missing seven out of eight targets and is required to make another £300 to £400 million of reductions in the next three to four years, how on earth can those be called “efficiencies”?
That is because we look to boards to transform the services to deliver them more efficiently and to improve the outcomes that they deliver.10:00
From memory, I think that NHS Lothian’s uplift was 6.4 per cent. I would be happy to provide accurate information to the committee if I have made a mistake, but it had a funding uplift. We have put in extra money to NHS Lothian over the past two years to bring it closer to NRAC—NHS Scotland resource allocation committee—parity. It is not unreasonable for the public to expect the NHS in Scotland to become more efficient year on year. That is why the programme of transformational change that we have in train is so important. The cabinet secretary will provide further detail to Parliament by the end of the year, and I have undertaken to write to the Public Audit and Post-legislative Scrutiny Committee by the end of the year confirming our framework for change, as requested in Audit Scotland’s report “Changing models of health and social care”.
It is not unreasonable to ask boards to make efficiency savings. Their budgets have not been cut. I am happy to say something about the eight targets if that would be helpful.
We might come to that. Almost every witness who has come before us has raised issues about cuts to services. The only people whom I hear saying that there are no cuts to services are senior managers in the NHS. If we have the highest-ever level of investment in the NHS, as has been stated, do you regard the “NHS in Scotland 2016” report as a glowing endorsement of management of that record investment?
I am not looking for glowing endorsements, Mr Findlay. As the cabinet secretary said, it is a balanced report, and we have accepted its recommendations. Among the recommendations is one on the importance of sustained transformational change, which is fundamental to delivering a safe, person-centred and effective health service.
I will ask one final question on the issue. What comment do you have for patients who have been waiting longer for treatment than they should because seven out of the eight targets have been missed?
I apologise to patients who wait longer than they should. I have done so in the past, and I regard it as appropriate and proper that I do so. We do not seek that patients wait longer than the targets that we have set, but, if I may say so, as far as I can determine—I have done some research—we are the only country in the world that tries to meet all those eight targets. I am happy to have stretch aims: It is part of our approach to improvement to set ourselves stretch aims and to do all that we can to transform to meet them. The cabinet secretary referred to Sir Harry Burns’s review. Now is the right point at which to review whether all the targets that we have are delivering the outcomes that we want. In the meantime, if we are not achieving what we said we would achieve, I apologise to those who have not been seen within the target time.
We were elected on a manifesto commitment to increase the health revenue budget by £500 million more than inflation by the end of this session of Parliament. That was higher than any other party’s proposal. No matter who was in government and putting forward a prospectus for Parliament, that is against a backdrop of increasing funding and increasing demands. For example, out-patient demands have been increasing over the years, but despite those huge increases, most people are being treated within the 12-week target for a first out-patient consultation. On in-patient waits, in quarter 2 of this year 91.2 per cent of in-patients were treated within the 12 week treatment-time guarantee. That is not good enough—we want everybody to be treated quickly—but it is important to make the point that the vast majority of patients are treated quickly.
We need to ensure that, through our transformation programme, we improve performance in a sustainable way. That will be done through, for example, our out-patient transformation work; our out-patient system is not as efficient as it could be. We need to ensure that capacity is used as effectively as it can be.
There is also the work that is being done by Sir Harry Burns. There has been political consensus for many years on this—spokespeople of all the political parties have, at one point or another, said that we need to ensure that the patient outcomes that we measure reflect the patient experience more accurately. Sometimes, our targets are more input-based than outcome-based. I accept that criticism, and I have asked Sir Harry Burns to look at our whole system of what we measure and why, in order that we can capture more accurately what the patient experience is. That is the work that we are doing.
We are short of time this morning, so I ask that answers be as brief as possible. Thank you.
Good morning to you both. I return to workforce planning. We use the phrases “workforce plan” and “workforce planning” a lot. I have a factual question. Is there a document or spreadsheet in NHS Scotland—a master plan—that shows across all disciplines current staffing and vacancy levels, predicted vacancies and recommended staffing levels in 2017-18? Does such a master plan exist physically?
It does, in that each board has that level of information and we have the information nationally. Also, the Information Services Division of the NHS in Scotland produces a lot of statistical information. The information is there.
The new bit of the regional and national workforce plan brings all that information together—what the picture is in the here and now and what it is projected will be required regionally and nationally in more granular detail. The workforce is probably going to change more than we have ever seen before. That requires us to make sure that, for example, in the primary care workforce we do not just produce more nurses and doctors in the specialties that we have, but try to land the numbers that are required as accurately as we can. Obviously, the nursing and medical workforce numbers and the training places all try to reflect what the needs of the service will be.
The work is different because it is about shifting the workforce into more primary and community care-based services. The workforce and what it looks like need to change. That is a new approach, and we need to take a national perspective on it.
What is not new, surely, is the need to project. You must have needed to project in 2010 and 2015—you must have some idea of what workforce you will need in 2017, 2018, 2020 and so on.
Of course we do. We are able to project the number of nursing, midwifery and medical training places that will be required based on analysis of the service’s needs. It is quite difficult to land that number 100 per cent accurately, but our workforce colleagues work very hard with boards to try and make sure—whether for undergraduate or for training places—that we land as accurately as possible the needs of the service, going forward. However, we will be in different territory in the next five, 10 and 15 years, because the services are going to change so dramatically, particularly because of the shift to primary care. That requires us to look in far more detail at how we create a new primary care workforce.
Good morning, cabinet secretary and Mr Gray. You have this morning used the buzzwords, as I call them, “transformation programme”, “reconfiguring services” and “local services”.
Things move on and we have to change and look at how we can do things better. Do local health boards do enough to explain what they are doing and why they are reconfiguring services? Too often the Scottish Government gets thrown at it the claim that it is concentrating services. When boards make decisions that local politicians do not like, they then ask the cabinet secretary to call in those decisions. Is there a better way of informing the public why services are being reconfigured, moved, concentrated or improved?
I think that some boards are better than others when it comes to service change proposals. Over the years, some boards have consulted the public in a good and meaningful way, with the result that, regardless of whether everybody liked the changes that were proposed, people have been more accepting of them because there has been proper consultation. There are also cases in which the process has not been handled quite so well.
However, the point is that boards will always look at the needs of their local populations. Sometimes service changes happen quickly because of patient-safety concerns or because inability to recruit key staff makes a service unsustainable. That has ever been so over the years.
I guess that what is new is that we now have the national clinical strategy, which provides the framework and blueprint for what services ought to look like in the future—from the more specialised services, which might have a more regional delivery focus, to what it is reasonable for people to expect their local hospital to provide, which will still be the majority of services. It also covers what more can be done in primary care—I am talking about services that, at the moment, might well be provided in secondary care, but which do not necessarily need to be.
The national clinical strategy is quite new. We have never had a blueprint for clinical services that lays out in that way what the vision should be. Obviously, we need boards to translate that locally and to make sure that what they do and the changes that they make are in line with that national policy.
I go along to some of the information meetings that the health board in my area holds, at which it tells us what it is doing. It annoys me that when the stories come out in the paper they are entirely different, and so the public perception is entirely different. What can boards do to improve the situation? Should they have more meetings, more social media coverage or more adverts?
All those suggestions might be justified and relevant. Communication is key. Boards must be able to set out not just why they want to make changes, but what the new service will look like. Describing and demonstrating what a new service will look like—which is not always easy—is sometimes the missing bit. Quite often, when we go back and talk to the public and patients once a change has happened, they think that the new service is better, but they might not have thought that it would be when the change was proposed.
Change is difficult—that will always be the case—but it is required. We are investing £500 million of additional resources in primary care and shifting that resource from secondary care, so change is necessary. I do not know what people think shifting the balance of care means, other than doing less in the acute sector and more in primary care. That is what it means, which means that services need to change. Perhaps someone here could tell me how else we can manage to invest that extra £500 million in primary care.
That is what will be done, but we must ensure that the public come with us on that journey and that they can hear about how much more can be done at their local health centre, which will avoid their having to travel miles to their local hospital or to a hospital much further away. I think that the public will get a better service, but we need to explain that.
I come back to the issue of efficiency savings, which I think relates to Richard Lyle’s point about taking the public with us when it comes to transformational change. We must be honest with the public on what is happening with regard to savings. The key message from the Audit Scotland report is that funding has not kept pace with rising demand. That is a fact. As the report says, health boards are having to make “unprecedented levels of savings”. They had to make savings of £291 million in 2015-16, and they are having to make savings of £492 million in 2016-17.
I have a question for Mr Gray and the cabinet secretary. Are you seriously saying to the public that every one of those savings that health boards are having to make is an efficiency saving? Are they entirely efficiency savings?10:15
You will recognise that, as I said earlier, all the parties put forward their prospectus for health funding, and my party’s commitment to provide £500 million above inflation was the highest of any party. That went in front of the public, who made their choice. The health service has now had an above-inflation uplift. Obviously, boards’ funding varies, but every board has had an above-inflation uplift.
Efficiency savings have always been part of changing the way that services are delivered. Every penny of those efficiency savings is reinvested in the front line. We expect boards to ensure that they make efficiency savings in the right way to free up resources for the front line.
You are right about demand rising. That is why Audit Scotland’s conclusion is that reform is required. Audit Scotland says that throwing more and more money at the NHS is not the key answer; the key answer is reform and doing things differently. We agree. Increasing levels of investment are not enough; we have to change the way that we do things, and we have to keep people out of hospital and treat more people in primary care and community services. I have not heard any alternative to the plan that we have proposed, and my plea is for people to get behind it.
There are some things that we need to stop doing and which we want to stop doing. The plan is not simply about trying to make everything better and faster. I am sure that the chief medical officer would be happy to brief the committee on her approach to realistic medicine, which, if implemented effectively, will mean that certain procedures of limited value will be stopped. We will not do them any more because they are of limited value. That discussion needs to be had with the public, and clinicians are much better placed to have it than I am. The plan is not about simply saying that everything will continue as is but will be a bit better and faster.
We have made efficiency savings. For example, NHS Fife has an efficiency programme to achieve greater compliance with the agreed drug formulary, and getting 80 per cent compliance in the board area will produce a saving of £8 million. Glasgow health and social care partnership has done work on a community respiratory team to support patients with chronic obstructive pulmonary disease. That work has reduced in-patient admissions, reduced the length of stay for those who are admitted and led to more efficient use of medicines and devices at home.
I will not give a great long list because I am conscious of the time constraint. There are things that will stop, but they will stop because they do not provide value, because we have better techniques, because there are improved treatments or because better drugs are now on the market. In no way am I trying to suggest to the committee that everything will remain the same. As the cabinet secretary said, it cannot remain the same and deliver what the people of Scotland need.
The question was about all the efficiency savings. Are you telling the committee that, of the £492 million-worth of savings that health boards will have to make in 2016-17, not a single one will adversely affect patient care? Are you telling the committee that every penny of those savings is an efficiency saving or a change in order to do things better, and that none of them is to do with balancing the books or will impact adversely on patient care?
It is important that the books are balanced but it is also important that patients get a good service. In the changes that they make, we expect boards to improve services by delivering them differently. They can be delivered more efficiently—Paul Gray has just outlined a small number of examples of how that can happen. If we do not encourage and support boards to make those changes, nothing will change. We need to ensure that every penny and every pound is spent most efficiently. That is a prudent way to manage the health service’s finances.
Nobody disagrees with that, cabinet secretary, but it did not answer the question. The reality is that, if we are going to take the public with us on transformational change, we have to be honest with them. It is not honest if we say to them that not a single penny of the savings that health boards are making will adversely impact on care. Staff and patients see that every day. Instead of simply dismissing funding matters as just efficiency savings and changes, why are we not honest with the public that the decisions are difficult and will impact adversely because there is not sufficient funding to meet demand? You cannot take the public with you unless you are honest that health boards will make cuts that will adversely impact on patient care.
But all those efficiency savings are reinvested in services that patients want and need. Efficiency savings are there to help to drive reform and change and to be reinvested in the front line. It is about doing things better and differently. Inevitably, some of those decisions will be difficult because, as I said, change is difficult. We work with boards to ensure that the efficiency savings that they have identified will make those improvements. We do not just sit back and tell boards to go and do whatever they want—it is a managed process. We require boards to discuss with us the level of efficiency savings, what those savings are and, importantly, what change they will deliver.
You mentioned your manifesto commitments on funding. Where in the manifesto did you commit to reducing local government budgets by £450 million? Has that been a good thing or a bad thing for social care and preventative healthcare?
The public made their choice based on the manifesto prospectus that each party put forward. We put forward a prospectus to increase health funding by £500 million more than inflation. The public made their choice and their decision—at the end of the day, that is what elections and democracy are about. We were very clear about our spending priorities. We have also transferred £250 million into social care, because we believe that it is important that we look at the whole system. Health and care are inextricably linked, and the £250 million for social care is delivering extra capacity in social care, which can get people out of hospital and keep them out. It is also delivering the living wage for 40,000 care workers, which I would hope the member would welcome.
I certainly welcome that, because I proposed it several years ago, but—
I need to stop you there, Colin. We have run over time because we started a wee bit late, and three members of the committee still want in.
I want to clarify and dig a wee bit deeper into some of the numbers in the budget so that I understand them a wee bit better. People are throwing about comments about cuts to this and cuts to that. Is it true to say that in 2015-16 the budget was £12.2 billion and in 2016-17 it is £12.9 billion, which is an increase in cash terms of £700 million?
That is correct.
Even taking into account inflation, the increase in real terms is 2.7 per cent.
So, overall, more money is going into the health service. There is twice as much extra money as you need to cover the rise in costs because of inflation. Those are the facts on what is going on.
The Audit Scotland report talks about £492 million in savings but, obviously, that is in the context of extra funds going in. Is it not therefore correct to identify that as a redirection of resources within the health service because, in effect, that £492 million is being moved to other areas of the health service, along with the extra £700 million that is going in on top? Is that a fair characterisation?
That is correct. Without doing that, we would not be able to resource the shift in the balance in the investment in primary care and the changes that need to be made. We cannot do that just with new money alone; we also have to shift the existing resources, which is partly what the efficiency savings do.
Absolutely. I just wanted to make that clear, because people look at that figure and think that it is £492 million of cuts, but there is in fact a £700 million increase in cash terms. Clearly, the issue comes down to what you deliver for that, but it is also true to say that there has been an increase in demand, with more GP visits, in-patient episodes and out-patient demand, plus the cost of drugs is going up. Therefore, in relation to what is being delivered for that money, which is the real measure of efficiency, is it true to say that we are getting more bang for our buck, if you like, in terms of the output from the health service?
Far more people are being treated in the health service than ever before. Out-patient demand, in-patient demand and demand for GP services are increasing. That is the point that Audit Scotland makes—demand is growing and we have to manage that and ensure that we use the collective resources and all the skills in the NHS to get people to the right place. That is the programme of reform and transformation that is under way. So, as you say, although there are additional resources in the NHS, including a redirection of existing resources, the caveat is that demand is growing.
Okay. I have a final point. It is clear that in the national clinical strategy and through integration and so on, there is a direction. Health boards are coming forward with proposals that they state are aligned with that, but each of those proposals would need to be examined to understand whether it was actually aligned with the strategy or whether the health board was just putting it in that context, but there was no alignment with the strategy.
It is clear that everything that a health board comes forward with does not necessarily comply with the strategy just because the health board describes it in that way.
At the end of its report, Audit Scotland talks about New Zealand, where Canterbury has made the shift towards more integration and community spend. Have you looked at that in detail? Do you have any understanding of how that was done and what it delivered in real terms? Currently, it is very much about having an aspiration that we think will save us money; in theory, it should, but, as the report says, we do not have hard-and-fast numbers. Does the New Zealand experience give us any confidence about how much can be delivered by going down that road?
We have looked at international experience, and we can draw some information from that, but every health service is unique. Therefore, the solution has to be a Scottish one. I am sure that there are lessons to be learned from elsewhere, but the plan and the strategies that we have are very much born out of the needs of the Scottish population and the type of systems that we have here.
Good morning, cabinet secretary and Mr Gray.
An aspect of Audit Scotland’s report that has not been touched on in the Parliament is to do with the estate. Repairs are needed to almost a third of all NHS buildings, there is a 50 per cent maintenance backlog and boards are now classifying maintenance requirements as “high risk” and “significant”. What programme are you aware of to address the estate issue? Are we building up a future NHS buildings crisis?
On Ivan McKee’s question, what do you think health inflation sits at?
Again, we can write to the committee with the details of this but, from memory, a recent report showed that there had been an improvement in the amount of work that had been done on the most urgent parts of the estate. It is also important to note that there has been continuing massive capital investment in renewing the estate. We should look at not just the hospital building programme, but the investments in new health and care centres and primary care facilities. There is a lot of capital investment going into renewing the estate and making it fit for the future. I am certainly happy to write to the committee with more details on that.
Health service inflation is 3 per cent.
Traditional pay and prices inflation varies from 1 per cent on pay to 10 per cent on drugs. Taken as an average across all the areas of expenditure, pay and prices inflation is between 2 and 3 per cent—it is probably closer to 3 per cent than 2 per cent.
We estimate that changes in demographics account for about 1 per cent per annum in costs. In other words, if the demographic trends continue, that will cost us another 1 per cent a year.
The figure is circa 3 per cent.
I will come back on both points. What is concerning for me about the estate is that the report says that both NHS Lothian and NHS Tayside, which are in the most difficult financial positions, have fallen back in relation to their estate, and the number of buildings that are at high and significant risk has increased. We really have to be aware of that and the decisions that are taken by those boards.
A number of people who have given evidence to the committee have said that they see health inflation at 6 per cent. There seems to be a lot of discrepancy in budgeting in the health service, with people working with figures of between 1 and 3 per cent, from what has just been said.
I cannot really account for what others say about inflation. We are saying that, from the work that has been done in the health department, those are the figures.
Should that be reviewed?
The gross domestic product deflator is 1.8 per cent. That is a proxy for general inflation. Inflation in health is around 3 per cent, taking into account the other aspects that Paul Gray talked about. That is the basis of our calculations.
Just to be clear, the Audit Scotland report has a figure of 3.1 per cent. That is what Audit Scotland thinks it is.
Given that we accept the Audit Scotland report, that is probably a good place to agree.
I suggest that there should be some correspondence with the health boards. My health board certainly tells me that the figure sits at 6 per cent. It is clear that we have a problem if the NHS centrally is working to a figure that is different from the one that boards are working to. Some correspondence on that might be helpful.
I am sorry, but I will have to finish the discussion there. I thank the cabinet secretary very much. There will be a brief suspension. We will try to catch up on time in the next evidence session.10:30 Meeting suspended.
10:32 On resuming—