Meeting of the Parliament

Meeting date: Wednesday, November 2, 2016

Official Report 1146KB pdf

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National Health Service (Audit Scotland Report and Service Development)

The next item of business is a statement by Shona Robison on the response to Audit Scotland’s “NHS in Scotland 2016” report, and service development.

The cabinet secretary will take questions after her statement, so there should be no interventions or interruptions. I call Shona Robison. You have a tight 10 minutes, cabinet secretary.

14:41  

I will today outline the Scottish Government’s response to last week’s Audit Scotland report and the process for considering the proposed service changes and developments that were debated on 28 September.

Audit Scotland has provided a balanced overview of the national health service and makes several recommendations that we accept in full.

Our NHS cannot stand still. It must continually evolve not only to deliver the best medicine and the best care, but to ensure that public money is spent as effectively as possible. Our clear vision to achieve that change has been acknowledged by the Auditor General for Scotland, who said last week that the Scottish Government

“has got a real vision to reshape services”.

Our strategy is founded on our twin approaches of investment and driving reform. We have made significant investments in our NHS. Since 2010-11, the annual health resource budget has increased by 8.2 per cent in real terms. The Audit Scotland report recognises the real-terms increases in investment in our NHS, and this Government will go further to ensure that the NHS receives the resources that it needs to be equipped for the future. For example, we are increasing the NHS revenue budget by £500 million over inflation over this session of Parliament. However, it is important to invest more than money and it is imperative that we drive reform.

As well as progress with integration, we have taken other steps this year to accelerate the shift in care in order to develop and to reform the delivery of health and care services. Increasing demands mean that we are accelerating change. We have shifted more NHS funding to support social care; we have published the national clinical strategy and the “Chief Medical Officer’s Annual Report 2014-15: realistic medicine”; we have accelerated plans for investment of £200 million in our new elective centres; and we are reviewing targets and indicators through work being led by Sir Harry Burns.

As part of a plan to increase health spending by almost £2 billion by the end of this session of Parliament, we will take the share that is dedicated to primary services to 11 per cent of front-line NHS spending. We will increase our investment in primary care by an additional £500 million, helping to shift the balance of care and meaning that, for the first time ever, at least half of our front-line NHS spending is being invested outwith acute hospitals.

Despite the challenges, our NHS is performing well, and its staff are to be thanked for working to address the increasing demand for services. We now have almost 1.5 million new out-patient attendances every year, which represents an increase of more than 13.2 per cent under this Government. Since 2005-06, 25 per cent more hip replacements are being carried out, but waiting times have reduced by 50 per cent. On cataracts, there has been a 30 per cent increase in procedures and a 40 per cent reduction in waiting times.

We know that more patients than ever before are being treated for cancer. Compared with 2010, there has been an increase of more than 1,000 patients per quarter in the number of patients who are included in the 62-day cancer waiting times standards. Performance against the 62-day standard is lower than we want, which is one of the reasons why we are investing £100 million over the next five years to improve cancer care.

In addition, Scotland’s core accident and emergency departments have been the best performing in the United Kingdom for at least the past 18 months; they outperformed England’s by almost 8 percentage points in August 2016.

The Audit Scotland report confirms that NHS staffing is at historically high levels. There are more than 11,000 more staff working in our health service than was the case when we took office. We are also acting to ensure that our medical workforce grows further. We are making it more sustainable and increasing the number of undergraduate medical school and specialty training places, as well as creating a new graduate entry medical school.

We are working to establish national and regional workforce planning, which will help us to deliver the direction that is set out in our national clinical strategy and to protect our commitment to no compulsory redundancies. Through that process, we will carry out work to address the cost of supplementary staffing, which will include efforts towards recruiting permanent posts when they are required and reducing agency spend. We will also use those workforce planning efforts to make better use of a staff bank system and framework contract when supplementary staff are needed.

As I have said, we have consistently prioritised investment in the NHS. We have increased front-line health spending and we will continue to prioritise front-line health services as we go on to increase the NHS revenue budget by £500 million more than inflation over the course of this session of Parliament.

NHS territorial boards received a 5.5 per cent increase this year compared with 2015-16 budget levels. That comprises an increase for front-line services of £224 million—an above-inflation increase—and an additional £250 million, which the new health and social care partnerships are using to invest in social care under our arrangements for integration.

We will consider the Audit Scotland proposal for three-year budget management as part of our work to examine how to provide NHS boards with more financial flexibility and within the context of the accounting and financial management framework that is set by the Treasury.

Despite the record level of resources that is being provided, we recognise the challenge of meeting increased demand. As the Auditor General for Scotland has made clear in her report, more needs to be done than simply giving the NHS extra money, which is why our plans for change are so important. I can confirm that, by the end of this year, we will set out in a single framework a transformational change delivery plan that will bring together the different strands of reform that I have set out. I will keep Parliament informed of progress.

I move on to service developments. Audit Scotland has made it clear that some reorganisation of services will be required, but that does not mean that every proposal that is made by every board will be approved. We are committed to robust, evidence-based policy making that delivers better outcomes. However, to stand against any change anywhere in acute services is simply not credible. Where change is advocated, we must ensure that the local boards work with all stakeholders to explore any issues and benefits, and I reiterate that any major change proposals must be subject to formal public consultation and ministerial approval.

I will now take the opportunity to update Parliament on the specific service changes that were debated last month. On cleft surgery, the recommendation endorsed by the Royal College of Surgeons to consolidate on a single site in Glasgow is distinct in the sense that it relates to a specialist national service as opposed to a local service. As such, I am now considering the proposal, in line with the precedent of ministers making the final decision on national specialist services. I have met the clinical teams in Glasgow and Edinburgh and, in the light of those discussions and full consideration of the evidence, I expect to make a decision before the end of the year.

Lanarkshire NHS Board’s longer-term plans as part of its local clinical strategy have been designated as major change by the board—boards can choose to designate proposals as major and follow the appropriate process without the need to ask ministers. The plans in question were subject to formal public consultation between 2 August and yesterday, and the board intends to consider the outcomes of that process at its meeting on 30 November. In doing so, it will be informed by the report of the Scottish health council on the consultation.

Any board decision made on associated specific major service change proposals will then be subject to my approval. What is beyond question is that all three acute hospitals will retain their accident and emergency departments for the benefit of local people.

At its meeting on 18 October, the NHS Greater Glasgow and Clyde board agreed that its proposals on paediatric services at the Royal Alexandra hospital be designated as major. The board will now undertake three months of formal public consultation, which is due to begin next Monday. The board is scheduled to consider the outcomes of the consultation by spring next year, as informed by a report on the consultation by the Scottish health council, and any board decision made on service change proposals will then be subject to my approval or otherwise.

The remaining proposals from NHS Greater Glasgow and Clyde—those affecting deliveries at the community maternity units at Inverclyde royal hospital and Vale of Leven hospital, those affecting in-patient care at the centre for integrative care and those affecting Lightburn hospital—are all subject to on-going public engagement. That process cannot be prejudged as it is possible that some or all of the proposals might change as a result—and, indeed, some might not proceed at all. The Scottish health council continues to monitor engagement activity and will offer a view on the designation of the proposals at the end of that activity, which is likely to be in early December. Ministers will then carefully consider the views on designation from both the health board and the health council and come to a decision. The board will then consider the next steps, as informed by the designation decisions, at its meeting on 20 December.

Although I will not prejudge those proposals, I reiterate that they must be consistent with national policy such as the review of maternity services that is due for publication soon. Moreover, I once again put on record this Government’s commitment to the vision for the Vale of Leven and say that any final proposals for Lightburn must address the concerns that led to our previous decision in 2011. I will keep Parliament informed as further progress is made on these proposals.

I believe that there is a clear case for a further shift from acute to primary and community services. I am confident that there is broad consensus on this, and that the Audit Scotland report supports that view; certainly no one and no party in this chamber has so far brought forward an alternative way forward. I believe that that consensus can be underpinned by the mutual recognition that our NHS continues to require increased investment and must reform to ensure that it remains true to its founding principles of being publicly owned and free at the point of need.

I am happy to take questions on my statement.

We now move to questions. Time is very tight, so the shorter the questions and answers, the more members who will be able to take part.

I thank the cabinet secretary for early sight of her statement. As we will debate the report later, I will keep my observations short.

Although much in the statement was not new, it is important to state that since the Scottish National Party first entered office almost 10 years ago, Audit Scotland has argued that, to change the way in which services are delivered, a shift is required from the traditional means of delivering services to community-based services. Almost every single Audit Scotland report since has noted that progress in that respect has been slow or non-existent and that funding has not been transferred from acute to community-based services at the rate that it should have been. As a result, although we welcome the announcement to shift the balance of care to primary care, the fact remains that it has taken far too long for this Government to take action. In this session, at least, it should not require two Opposition debates and a damning report to spur the Scottish Government to take steps.

I want to ask the cabinet secretary two questions. First, NHS staffing is clearly an issue on which we on this side of the chamber have concentrated. Will the Scottish Government commit to publishing a national workforce plan immediately and to presenting an update to the Scottish Parliament every six months?

Secondly, in light of her announcement that the share of primary services spending will rise to 11 per cent of front-line NHS spending, can the cabinet secretary tell us specifically how much of that money will go to general practice?

Donald Cameron talks about the time that it has taken to shift the balance of care. I think that all health systems would acknowledge that that is a challenge and a difficult thing to do. However, one of the Government’s big achievements in moving towards the shift in the balance of care has, of course, been the integration of health and care services. That is one of the biggest reforms that there has been in the public sector in a generation. Although I accept that the pace needs to be increased, it should be recognised that there has been a substantial leap forward in shifting the balance of care through the integration of those services.

We have already set out our plans to develop national and regional workforce plans. We will publish a discussion document by the end of the year, because stakeholders want to be involved in that. I am happy to take on board Donald Cameron’s suggestion about six-monthly updates and to look at whether they can be delivered. If they can, we will do that.

I am sure that Donald Cameron will welcome, as I do, the First Minister’s announcement on increasing the share of spend on primary care services. However, that will mean change, as it will mean increasing the shift in the balance of care from acute services in order to deliver it to primary care services.

Donald Cameron will recognise, as well as I do, that it is not just about investing in general practice, although we will do that—he knows that we are working on a new contract with the British Medical Association—it is also about the wider primary care team. The workforce plans that we will set out will address not just general practice, but the wider primary care team.

I thank the cabinet secretary for prior sight of the statement.

The truth is that the cabinet secretary has been dragged kicking and screaming to the chamber. A week after the worst state of the NHS report since devolution, she is before us armed only with warm words. There is no recognition of the crisis in the NHS, no acceptance of her Government’s role in the failures and no plan to reverse the damaging cuts to front-line services. The Government is letting down the staff and patients in our NHS.

We will focus on the Audit Scotland report in the debate later. I want to focus my remarks on the proposed service changes.

It is disappointing that the cabinet secretary chose not to accept the will of Parliament in the statement. In fact, she has said nothing new. There is no comfort for communities that face the loss of vital local services and valued local input. I will give one example. How can the cabinet secretary come to the chamber and say that the complete closure of Lightburn hospital—not a ward closure or a downgrade of services—is not a major service change? What we have—

Mr Sarwar, you are almost at the end of your time, and you have not asked a question yet.

I am just coming to the question, Presiding Officer.

Please hurry up.

The minister is clearly out of her depth. On “Good Morning Scotland” on the day that the Audit Scotland report—

Mr Sarwar, will you ask a question, please?

This is my question, Presiding Officer.

The cabinet secretary said on “Good Morning Scotland” that, in Parliament, Labour was

“putting blocks in the way”

of any service changes. Can the cabinet secretary clarify which service changes she was referring to and whethers every promise about local NHS services that her party made before the election will be kept?

Anas Sarwar’s contribution to the debate shows that he has nothing to say other than personal abuse. That is a thin fig leaf for having nothing to say about the NHS.

Unlike Anas Sarwar’s contribution, the Audit Scotland report was balanced and it recognised some of the achievements of the hard-working staff in our NHS. We have the right strategies in place and Audit Scotland says that we do. The Opposition has no plans and no alternative vision for the NHS. We have the vision and the strategies, and Audit Scotland says that they are the right ones.

On the will of Parliament, I have come here and laid out the decisions that I will make on the service change proposals that are coming to me. There may well be a major service change proposal relating to Lightburn hospital, but we are not at that stage. If it gets to that stage, the matter will come to me for a decision. I made it very clear in my statement that, on 20 December, NHS Greater Glasgow and Clyde will decide which service change proposals—if any—it will continue with. It would be wrong to call in a service change proposal that might not even exist at the moment. I would have thought that even Anas Sarwar would understand that part of the process.

I suggest that Anas Sarwar goes and does his homework, and perhaps comes back to the chamber a little more informed than he has been today.

When front-benchers overrun their time, all it does is penalise their colleagues.

The Scottish Government announced the review—chaired by former chief medical officer Sir Harry Burns—of health and social care targets and indicators that was advocated by the British Medical Association, the Royal College of Nursing and other medical colleagues. Can the cabinet secretary confirm that certain performance targets, such as 95 per cent of patients being seen in accident and emergency within four hours and cancer treatment targets, will be retained in the wider work?

As I have said previously, the work of Harry Burns in reviewing the targets is very important and the review has the support of the majority of members in this chamber. It is important that we look at the outcomes for patients and that our targets better reflect those outcomes. That is something that the royal colleges and many other stakeholders support.

I have made a couple of things very clear. It is very important that cancer targets are used to improve care and treatment for cancer patients. That is why we are investing £100 million of additional money in the next five years and we expect any review of cancer targets to reflect our ambitions to improve care and treatment for cancer patients.

The Royal College of Emergency Medicine and I feel strongly about the four-hour accident and emergency target. It is a barometer of how the whole hospital is performing so I will take some persuading to move away from it. However, it might be that it could be made more sophisticated in nature and I am sure that Harry Burns will consider that.

I thank the cabinet secretary for the advance copy of her statement.

Page 15 of the Audit Scotland report has NHS Lothian’s financial position as a case study. Given that NHS Lothian, NHS Tayside and NHS 24 all continue to face major financial difficulties, what assurance has the cabinet secretary been given that that will not impact on patient care?

The Royal College of Surgeons supports the principle of the centralisation of cleft surgery, but it has said that its role is not to advise on a location. The cabinet secretary’s statement is clearly misleading on that. Will she correct that?

The uplift to NHS Lothian for 2015-16 was 6.4 per cent. NHS Lothian has, of course, been an NHS Scotland resource allocation committee beneficiary, but I recognise some of the challenges that it faces. My officials have been working closely with NHS Lothian to address out-patient waits, for example, and I will have more to say about initiatives on improving out-patient performance in a few weeks.

I laid out very clearly that the decision on cleft surgery has now come to me. The college’s view has been made very clear indeed. I had a productive meeting with the Glasgow surgeons and the Edinburgh surgeon and her team. I now want to look at all that and come to the right conclusions about what is in the best interests of patients across Scotland. I hope that Miles Briggs will appreciate that that will be the founding principle of my decision.

Staff banks can provide boards with access to a pool of appropriately trained non-agency staff who can provide short-term supplementary cover when required. I am sure that the cabinet secretary will join me in commending those who give of their time in that way, often at short notice.

Of the total nursing and midwifery staff in NHS Scotland, what percentage is agency staff? What is the Scottish Government doing to reduce reliance on agency staff?

Next is Jenny Marra, to be followed by Bob Doris. [Interruption.]

I am sorry. I am so determined to get through everyone.

Thank you, Presiding Officer.

I will answer Clare Haughey’s question first by commending the work of all staff in our NHS. She has made an important point. Agency nursing represents approximately 0.4 per cent of the total nursing and midwifery staff in NHS Scotland. It is proportionally a very small figure, but it is still too high. That is why we have a programme of work under way nationally in which we are considering with NHS boards how we can have more effective management of all temporary staffing. We are working with boards to reduce reliance on, and the costs of, temporary agency and bank staffing. The team is ensuring that when temporary staff are required, agency staffing is the very last resort. As part of that, we have implemented monthly agency spend reporting to ensure that boards are informed of their spend and know where to focus their attention in addressing the matter.

May we now have Jenny Marra, to be followed by Bob Doris?

Spending on agency staff is certainly too high in NHS Tayside. The cabinet secretary will know from the report that Audit Scotland has just published that that spending has increased by 39 per cent just over the past year. How will the framework contract that she mentioned in her statement assist with that critical overspend in NHS Tayside?

Jenny Marra makes an important point. There are big disparities between boards’ spend on agency staff—some are spending far more than others. We absolutely want to address that, and we are working with NHS Tayside to address it. There are regional variations—some boards find it harder to recruit permanent staff, but bearing down on agency costs is without doubt critical in this case. We have made it clear to the management team in NHS Tayside that we expect it to do that as a matter of priority, and we will help it to do that.

Part of the solution is to convert some of the agency spend into substantive posts, so we are helping boards to do that. The work that I have announced in relation to the workforce element of the delivery plan—both the national workforce plan and the regional one—will also help us to plan the numbers of nursing and midwifery posts that will be required going forward so that we can ensure that we have the right training places and the right numbers in the right places to support that. I am happy to keep Jenny Marra updated on the work that we will take forward with NHS Tayside specifically.

Audit Scotland highlights in its report that NHS Greater Glasgow and Clyde has an impressive record on key NHS indicators, including the treatment time guarantee and referral to out-patient appointments, as well as a 30 per cent fall in bed days lost via delayed discharge. However, its accident and emergency performance was not impressive compared with that of other Scottish boards. How will we use the report to ensure that best practice is shared among boards so that we constantly drive up standards and, of course, performance?

Bob Doris raises some important points. The 30 per cent fall in lost bed days in NHS Greater Glasgow and Clyde has been impressive. We have been looking at what the board has done with its partners and we are keen that other integrated partnerships follow suit in order that they use the best ways of reducing delay. We know what works and we want other partnerships to follow that. NHS Greater Glasgow and Clyde has led the way on that.

On A and E performance, Bob Doris will be aware of the huge programme of work on delivering six essential actions—the six things that we know must be done in order to improve A and E performance across the board. The performance across the board over the past 18 months is the best in the whole UK; it has dramatically increased and improved, which shows that the programme of work on the six essential actions has worked. Glasgow has had more of a challenge, and there have been particular challenges at the Queen Elizabeth university hospital and Glasgow royal infirmary. However, my team of officials has been working closely with NHS Greater Glasgow and Clyde to address those issues and I am confident that that work will bear fruit and that the board’s performance will improve.

Investment in prevention is key to reducing demand for NHS services. What action is the Scottish Government taking to develop a truly integrated public health strategy, as was called for in Audit Scotland’s report? Today’s statement did not address at all the urgent need for a truly integrated new public health strategy with a focus on prevention.

Alison Johnstone makes an important point about prevention. She will be aware of the review of public health and of the fact that we will have a new public health strategy. We are looking at how best to consolidate the public health resource so that it can deliver a service not just to the NHS but to the rest of the public sector—local government in particular—to help decision makers to make the right decisions based on data and what the evidence tells us about the needs of the local population and, more importantly, what programmes within public health and prevention will work to keep people out of our hospitals by stopping them from falling ill in the first place. I am happy to keep Alison Johnstone updated on the progress of that new public health strategy and bringing the public health resource into one place, and on the benefits that I think it will deliver.

I call Brian Whittle. If he is very quick, I can call Colin Smyth.

I was disappointed that, in the cabinet secretary’s statement, there was not one mention of tackling the alarming rise of the serious preventable disease epidemic. When is the Government going to give proper thought and attention to a sustainable plan to address prevention of ill health and growing health inequality?

As I have just said to Alison Johnstone, Brian Whittle will appreciate that a huge amount of work has gone into the public health review, which will help us not only to bring the public health resources and workforce together in a more coherent fashion, but to make sure that that delivers the changes that Brian Whittle is talking about. Those changes cannot be delivered just by the NHS: this is about the whole of the public sector—not least, local government. I am keen that we give prevention and public health greater focus. The review has helped us to find a way forward to doing that. I am happy to keep Brian Whittle updated on progress.

The Audit Scotland report describes the cuts that are facing health boards as “unprecedented”—£293 million in 2015-16, rising to £492 million in 2016-17. Does the cabinet secretary still believe that the cuts are merely efficiency savings? Is she prepared to say to Parliament that not a single penny of those cuts and not a single measure that is taken to make those cuts will impact adversely on patient care?

By the end of this session of Parliament, we will have increased health funding by almost £2 billion—building on the £3.3 billion increase that has already been delivered under this Government. By the end of this session, health funding will be at least £500 million more than inflation-only increases. That was the highest offer of any party in the Parliament, including Colin Smyth’s party, which had the lowest offer on health funding of all the parties.

Please could you close now, cabinet secretary?

I will take no lessons from the Labour Party about health funding. What is important, though, is not just the amount of money that is going into the NHS, but what the money is spent on. That is why we need to shift the balance of care, with an additional £500 million going into primary care by the end of this session—

Please close now, cabinet secretary.

I hope that the plans will get support from all across the chamber.

On a point of order, Presiding Officer. This is the first opportunity that Parliament has had since the publication of the damning Audit Scotland report last week to discuss the report, yet we have had five sycophantic questions from members of the Government’s party to pad out time but have not been able to call a member from every party in Parliament. Can we please extend the time for questions?

We had six Opposition questions and three Government questions. If that is an issue, please take it up with your business manager. There can perhaps be a discussion among all parties about asking questions rather than making statements, and giving back-bench colleagues the courtesy of allowing them all to take part. There is a debate on the same subject later this afternoon. [Interruption.] Histrionics will not change my mind, Mr Cole-Hamilton.