Health, Social Care and Sport Committee

Meeting date: Tuesday, December 21, 2021

Official Report 600KB pdf

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Budget Scrutiny 2022-23

Welcome back. Our third agenda item is an evidence session with the Cabinet Secretary for Health and Social Care as part of our scrutiny of the budget for 2022-23. I welcome to the committee the cabinet secretary, Humza Yousaf, who is joined by Richard McCallum, the director of health finance and governance for the Scottish Government.

I have a broad question for the cabinet secretary. How does the budget start to put in place funding for the Government’s manifesto commitments from earlier this year?

Good morning, convener, and good morning to all members who are present. I hope that you are all keeping safe and well. Although I am pleased, as always, to appear before the committee, it is a shame that the session has to be done virtually because of the constraints that are on us. I look forward to being with you face to face.

You asked a really good question, convener. The budget that we have put in place helps us to build on the manifesto commitments that we have already achieved this year. It is important to recognise that, in the first 100 days, we made an incredible amount of progress in meeting our manifesto commitments, including abolishing dental charges for people aged under 26.

We have gone beyond what we promised to do in the first 100 days—for example, we have introduced the paramedic bursary, which members across the committee were very supportive of, and we have put in place the first steps for the national care service. I will no doubt come back to that. We managed to bring forward many other commitments in the space of 100 days, including the pay rises for not just agenda for change staff but doctors and dentists.

There is a lot that we have done in this financial year that we hope to build on in the next financial year, and the budget goes into great detail on that. One of the key, significant reforms that we hope to progress will undoubtedly be the national care service. That will be the biggest public sector reform in the devolution era. We hope that that will be fully operational by the end of the parliamentary session, so we are putting in place the appropriate building blocks for it.

Crucially, we have funding in the budget to help us to progress with the national recovery plan, including the increase to health boards, which I can go into detail on if necessary. That will help to drive the recovery. We need to make sure that we recover as well as deal with the effects of the pandemic.

A lot of resource is going into capital. Members can see some important projects in the capital allocation, such as Parkhead health centre and the Baird and ANCHOR—Aberdeen and north centre for haematology, oncology and radiotherapy—project, and the money to progress the replacement for Monklands hospital, which is also much needed.

I am sure that we will get into the detail of this, but the big uncertainty continues to be the UK Government’s lack of transparency in relation to Covid funding. We desperately need certainty on that because, as we all know, we are not yet through the pandemic. This meeting being conducted virtually is testament to that.

Thank you. Gillian Mackay will ask questions specifically on Covid-19.

It is very obvious when we look at the budget allocations that the Covid-19 spending last year was significant, but there is nothing against that this year. To put it mildly, there is some confusion about the allocation of money from the UK Government that was announced last week. There is a dispute over whether that is money that has already been allocated and is accounted for in the budget, or is money that is still to come. That will impact on the health budget, because it will, I presume, be allocated to things such as the vaccination booster programme. Can you give us clarity on what is happening there?

I wish that I could, convener. That is exactly the point that you are making. I will not delve too much into what happened last week, but it was extremely poor that those kinds of silly political games were being played in the midst of a global pandemic or, certainly, at the foothills of another wave. When the First Minister got to her feet, there was a press release from the Treasury that claimed that there would be new money, but it was nothing of the sort. Indeed, there was a potential reduction in the consequentials that are coming our way. Those consequentials are vital, as you have rightly said, in dealing with the effects of the pandemic and for the crucial tools that we have in our armoury against the virus, such as vaccinations and test and protect.

On the UK Government spending review, the Covid consequentials were far less than we had expected, given how much has already been spent on fighting the virus and the fact that the virus has not yet gone away. We desperately need certainty from the Treasury about the amounts of money and how the money will be spent. As members can imagine, I push the Secretary of State for Health and Social Care on those issues in my regular four-nations calls, as do the Welsh and the Northern Irish. In fairness, he is always constructive in those conversations, but there has been no clarity forthcoming, which is deeply concerning.

I do not know whether Richard McCallum wishes to add to that. He is involved in discussions with finance colleagues at an official level.

I have a couple of things to add about next year and the 2022-23 position. As the budget sets out, no formal Covid-19 consequentials have been agreed for next year. However, there are two critical points to make on the issue. Clearly, in relation to the money that we have agreed for the health portfolio, there are a number of things that we are taking forward to respond to the pandemic. The money that we have invested in waiting times improvement is a direct consequence of the pandemic, and we are investing that as well as we can. The money that we have put towards social care is designed to support the overall system, partly because of the pandemic, although it will have a longer-term impact as well. We are doing what is in our power and in our gift to make those decisions now.

The cabinet secretary made a point about the on-going measures in relation to test and protect, vaccinations and personal protective equipment. We are working on those key areas as closely as we can with the Department of Health and Social Care and the Treasury, because they are the areas in which it is likely that we will continue to need quite significant spend and in which we do not have clarity. Some of that is understandable, because we do not know what the future will hold, but those are the areas in which certainty is most needed.

Colleagues will dig into that further. As I said, Gillian Mackay in particular has questions on Covid-19.

The programme for government sets out longer-term spending commitments, but there is no medium-term framework in place. That is understandable, because we are dealing with an acute situation. In relation to our scrutiny, will more evidence come forward about informing decisions and the allocation of increasing budgets? For example, we want to keep an eye on the sum of £2.5 billion that has been promised over the course of the parliamentary session, and on the balance of care, with regard to the commitments that more than 50 per cent of front-line national health service spending will go to community health and that there will be a 25 per cent increase in primary care spending. Can you give the committee an idea of the medium-term plans?

That is a fair question, convener. As we have recognised already, the health and social care medium-term financial framework will have to be updated in the light of Covid and other significant changes, such as our work towards a national care service. The framework considers available resource and demands but, obviously, it does not set our budget. Our budget is informed by key policy priorities and the national performance framework, to ensure that commitments and linked budgets ultimately contribute to the delivery of desired outcomes.

A recent study by the London School of Economics and The Lancet suggests that 4 per cent real-terms growth in healthcare costs is to be expected, to ensure improving quality of care and terms and conditions for the health and care workforce. That is very much in keeping with the assumptions that underpin the current medium-term financial framework. I have no doubt that that, as well as other independent research, will inform our view. However, there is no doubt that, given the pressures and challenges of Covid, we will have to look at that medium-term framework once again.

Thank you. Sue Webber has a supplementary question on that.

Cabinet secretary, you spoke a bit about the lack of transparency, and you also mentioned “silly political games”. Therefore, I wonder how you would tackle something that has come from our own auditors. Audit Scotland has called for greater transparency, particularly around Covid spending, and has said:

“The Scottish Government now needs to be more proactive in showing where and how this money was spent”.

That also relates to the underspend of £292 million in the health and sport budget. We have also heard a response to that from Scottish National Party members in Westminster and your Cabinet Secretary for Finance and the Economy that the money has been carried forward. I was a bit concerned about that transparency because, when it comes to Covid spending, we see only one line for that in the budget for last year—it is not broken down into categories at all. That carry forward is not apparent anywhere in the two tables that I am looking at. Where is that carried forward money sitting in the budget that we are looking at?

We can give you the detail of that. We will always look at any Audit Scotland report in great detail and consider its findings. You might have seen that the finance secretary addressed some of the issues in the Audit Scotland report.

On resource, it is important to say that it was well documented last year that very late consequentials that came in in the last few months of the year would have to be carried forward to ensure that vital programmes, such as vaccination programmes, could continue. Vaccination programmes do not stop at the end of the financial year, so we have a budget for the full initiative.

On capital, there is no doubt that lockdown had an impact on the ability to complete projects within the set timescales. Our portfolio was the most affected, along with transport and infrastructure. Contrary to any claims, the economy budget was overspent.

It is important to digest the full detail of the Audit Scotland report. With regard to transparency in the budget, I am always happy to consider members’ suggestions about how we can be even more transparent than we are. I might bring in Richard McCallum on that, as he might have more details. If Ms Webber wants to know about any specifics, she can respond after he has spoken.

On the information that we provide to Audit Scotland and others, I want us to be as clear as we can be about not just all the Covid moneys that we have spent but our whole portfolio. I engage with Audit Scotland every month to update it on our financial plans and talk it through our position, and I will continue to do that. As a general point for the committee, if more information is required, either on specific funding lines or on the general budget position, we would be happy to provide that information.

11:15  

On the point about the underspend at the end of 2020-21, as Sue Webber said, it was £292 million for the portfolio. That relates to two things. The first is the timing of the consequentials, which the cabinet secretary mentioned. In January 2021, we got confirmation of some funding. The timing of that meant that, in order to use that as efficiently as possible, the funding had to be brought into the new financial year. That accounts for the bulk of that underspend.

The second aspect is a bit more technical and relates to PPE spending. We agreed with the Treasury that, for Treasury purposes, we would account for that on-cost but that, for the purposes of the Scottish Government budget, we would show that by way of stock held. That is a bit of a technical accounting issue, but I can provide more information if needed. That increased the underspend, but it was done in agreement and alignment with the Treasury.

The reason why that money does not show in the 2022-23 budget is that it was carried forward into 2021-22—it was carried into the current financial year rather than the future financial year, which is what the budget is looking at.

Sandesh Gulhane has questions on health board budgets.

NHS Ayrshire and Arran overspent on previous budgets, as have a number of health boards. It also looks like NHS Ayrshire and Arran requires significant transformational change, particularly in acute services. To me, that is a bit of a worry, given where we are at the moment.

My first question is: will you write off health boards’ previous budget overspends? My second question is: what is being done with regard to the significant transitional changes that are required in relation to NHS Ayrshire and Arran?

As I am sure Sandesh Gulhane knows, NHS Ayrshire and Arran remains at level 3 on the escalation framework, which is a serious position for it to be in. That is specifically in relation to financial management. As you would imagine, we continue to act in line with level 3 escalation, and we are undertaking scrutiny and the provision of support in line with that framework. Of course, financial recovery remains a priority for those boards, and the focus has been on the response to the pandemic, which has undoubtedly impacted on their financial recovery plans.

We maintain a regular dialogue with NHS Ayrshire and Arran. As you can see from the budget for 2022-23, it is in receipt of additional funding, but we have put in place additional monitoring for that board and the other escalated boards to ensure that appropriate steps are taken in terms of cost improvement and efficiency in advance of 2022-23.

I remain concerned about NHS Ayrshire and Arran and also about NHS Borders and NHS Highland. NHS Highland was recently, of course, subject to a section 22 report in relation to finance.

Would you be looking to write off a proportion of the debt that the health boards have accrued?

Again, we will work closely with the boards on how we can support them. We want them to get to a substantially sustainable level. Like any Government, we would always consider writing off the debts of health boards and similar bodies, but that comes at a cost somewhere else in the health budget, and it is incredibly difficult to find that money when we are in a situation in which every penny is allocated.

We want NHS Ayrshire and Arran to be able to stand on its own two feet financially and to have in place the financial mechanisms and controls that can get it de-escalated from level 3 of the framework. That is certainly what Audit Scotland would expect.

Richard McCallum might want to add more to that.

I will add a couple of points.

Dr Gulhane’s question is really important. Over the past 20 months, our approach with boards has been about balancing on-going financial management and scrutiny with the realities that they have needed to focus on, such as the immediate issues of dealing with the pandemic. A transformation programme does not happen just in a finance department; it needs to happen hand in hand with clinicians and those who work in the service. We need to strike an important balance between asking boards to continue good financial management, scrutiny and transformational change and recognising, at the same time, the pressures that they are under in dealing with the pandemic.

With that in mind, in 2020-21, we took an approach—we will do so again this year—of not providing brokerage. Instead, we will support all boards with Covid funding, which will allow them to balance their financial position this year, as all boards did last year. We recognise that there is an element of unachieved savings, because boards have not been able to move forward with their savings plans, as they might normally have done pre-pandemic.

The cabinet secretary raised a point about keeping boards that have been financially escalated under enhanced measures, so that we get monthly reporting from them that shows what they are doing with their financial planning. While the pandemic goes on, the transformation work has not stopped, and we have continued to discuss with the boards the steps that they have in place.

Going beyond that, we have asked all boards for three-year service and finance plans for 2022-23 and beyond. That will tie in with the spending review when it comes in in May. That is when we will look to get greater assurance and certainty about boards’ financial plans moving forward.

I have looked through the details of the money that has been provided to boards, and it appears that the amount spent on distinction awards has come down. Are we still giving out new distinction awards or have they been phased out?

I do not think that we are giving distinction awards. We took a decision not to do that. Richard McCallum might want to provide further clarity.

That is correct. The reason why the money is reducing each year is that new awards are not coming in. That budget line will probably continue to reduce, because new awards are not being provided.

It is a number of years since we took that decision.

The more detailed table says that the distinction awards are

“designed to provide competitive remuneration packages for consultants and ensure we attract and retain the right calibre ... of employees”.

Without the distinction awards, how are we achieving that?

There are a number of other ways that we can look to recruit and retain. Under this Government, there has been an incredible increase in the number of medical consultants since 2006, which we are pleased about. However, I take the point about retention.

We are looking at a number of avenues—one is to make sure that people are well remunerated, and another is to look at pensions. Some of that is within our gift, but a lot of it is within the UK Government’s gift, and I have been having discussions with it about potential pension changes. I think that Dr Gulhane is a member of the British Medical Association, so he will probably know that it has written to me about whether the Scottish Government can do more in relation to pension changes that would help with retention.

There are a number of other avenues that we can look at instead of distinction awards, which we have not provided for a number of years. I will work closely with the BMA and others to ensure that Scotland is a competitive place when it comes to not just recruiting but retaining more consultants, which is key to your question, Dr Gulhane.

I see that Sue Webber has a question. Sue, I have you down to lead our questions on capital budgets. If you have a supplementary question on health boards, please move on to that theme afterwards.

I represent the area that NHS Lothian covers and I was disappointed by the distance between its allocation and the NHS Scotland resource allocation committee recommendation—[Inaudible.]—£12 million.

Richard McCallum said that you are prioritising funding for health boards that are struggling to deal with the pandemic—to be fair, most boards are struggling with that to some degree. However, the greatest percentage increases are going to the national boards, not the local ones. The national boards include the NHS National Waiting Times Centre, which provides planned elective services, but the boards that are really struggling are the ones that have accident and emergency departments and deal with emergency admissions.

Why was the decision made to give more, proportionately, to Public Health Scotland, NHS National Services Scotland, Healthcare Improvement Scotland and the waiting times centre, rather than other health boards?

Every health board is receiving an uplift, which is important. I completely accept that you will go out and bat for NHS Lothian, given your role. Why would you not do that? However, every single health board faces significant challenges. When I look at the figures, of course I see that the A and E department at the Royal infirmary of Edinburgh faces a challenge. However, if I look along the M8 to the Queen Elizabeth university hospital, to Forth Valley royal hospital or to Aberdeen royal infirmary in NHS Grampian, I see that A and E departments across the country are under significant pressure and are significantly suffering. Our NRAC formula, including the funding that we use to ensure that boards are within 0.8 per cent of NRAC parity, assists health boards across the country.

The funding to the non-territorial boards is vital. You mentioned the funding for Public Health Scotland. When we think about how crucial that board has been to our fight against the virus over the past 20 months, I do not think that anyone would argue—and you are certainly not arguing—that we should take money away from it to spend elsewhere.

All boards, territorial and non-territorial, are important. We have record investment of £18 billion in the health service. This is the first time that we have been able to finance health and social care to such a level. There is significant funding.

I give you an absolute promise that I meet NHS Lothian very regularly and I have a great amount of faith in the ability of the management team, the chair and the board to put the money to good use to improve what is a very difficult situation right across Lothian.

Thanks. I have great admiration for NHS Lothian, too.

On the capital budget, you mentioned the Baird and ANCHOR project and the Parkhead health and social care centre in Glasgow. In the past, people have levelled at me the claim that there is not enough investment in building new GP infrastructure across the country. We might get one significant general practice funded in any Government’s term of office. Will there be more detail on that in the capital investment strategy? When will that strategy be published?

You ask a good question. As you can see, we will invest a significant amount of money—[Inaudible.]—in the Baird family hospital and ANCHOR centre project. That is important. You will also see in the capital funding figures that there is significant funding for Parkhead of more than £30 million in-year. That is our biggest investment in a health and social care centre, which is the model that we want to take forward where it works, albeit that it is not appropriate everywhere.

We know that, in health and social care centres, we can get the appropriate support in one place for the public that they serve. That can be exceptionally helpful, particularly when it comes to reducing demand at the front doors of our acute sites. You talked about that issue earlier. I add that, through our manifesto, we have committed to spend £10 billion on health infrastructure over the next 10 years. That is a really ambitious target, so we will have to ensure that we profile the spend appropriately over the decade.

11:30  

You asked about the capital investment strategy, and you are right to suggest that it will be key to some of the important funding decisions. We intended to publish the strategy after the Infrastructure Commission for Scotland published its report on 20 January 2020, but we have, of course, been focused on the response to the pandemic. We therefore do not have a date nailed down, but I promise Ms Webber that the strategy will be published as soon as it can be. She is right that it is an important document that will give people at least some comfort and reassurance that those important capital projects are being taken forward.

On the £10 billion, you have talked about refurbishing health infrastructure. Does that specifically include technology that is within hospital infrastructure? We are talking about capital, which should include theatre tables, new theatres and buying newer and better technology. I am aware of a specific experience in Glasgow where a hospital was unable to buy a new theatre table or certain pieces of equipment but it was able to lease them at £2,000 a time. That did not make much sense to me when I looked at the number of times that it was looking to rent versus the overall spend. I am trying to gauge what might be possible. I know that the level of capital that gets down to that granular level is not always significant enough to invest in what is needed for services.

We have not yet made any final decisions on how that money will be earmarked, so we have not given full detail of that. We have to look at what the health board wants to fund and whether it could be financed through capital or resource. You mentioned theatre tables as a specific example. Capital projects are, of course, important investments to make. We need to give health boards the ability to renew their equipment where possible. However, the real focus of our capital infrastructure programme will be on significant refurbishment and significant replacement and build of assets.

Richard McCallum may wish to comment on the specifics around theatre tables being—

That was just an example.

I know. The point that you make is important. I am genuinely not—[Inaudible.]—focus on the big projects; there is also a question about smaller projects.

It is a really important point. That is just one specific example. The capital strategy that we will produce will include an equipment replacement programme, because we know that that is a challenge and a risk for health boards. That will make sure that boards are working forward with a clear plan and design for those things. Over the past year, we have worked with all the territorial boards to look at their equipment replacement plans, and we have built that into the workings that we have done as part of the capital investment strategy.

Paul O’Kane has a supplementary question.

My question follows on from the point about the £10 billion investment over the next decade. Given that health capital budgets are typically around £500 million, it is clear that there will have to be quite a detailed uprating, and I am keen to understand where you think that that will come from. A huge amount of capital promises have been made within that, whether in the plan that has not yet been published or in the manifesto—for example, in relation to refurbishment of the Royal Alexandra hospital and the Vale of Leven hospital in my region. There is already a £76 million repair backlog at the RAH. I am therefore keen to understand how and when we will profile those things.

That is a very fair question. Some of it goes back to what I said to Sue Webber. Given the capital infrastructure projects that we are currently dealing with—the biggest one in my in-tray is the replacement of Monklands hospital—we suspect that most of that money will be backloaded to the latter years of that 10-year spend.

However, that is why the capital investment strategy for health will be published sooner rather than later. I do not have much to add to what I have already said to Ms Webber. I hope that people understand why the strategy was delayed, but I also accept the challenge from elected members that they need some certainty. I guarantee that we are working on the investment strategy and we aim to publish it as soon as possible.

We move on to questions on Covid-19 health spending.

Given the new variant, have estimates and identified funding allocations changed in the 2022-23 budget?

It is a developing situation. I go back to my initial remarks to the convener: we are perplexed by the level of Covid consequentials and funding that the UK Government has put on the table. It may be that that is its initial estimate and it will add to that as circumstances dictate, but for us it is deeply concerning.

The omicron variant adds financial pressure, without a shadow of a doubt. I have heard Gillian Mackay speak on the issue in the chamber, so I know that she is well aware that, with additional resource, we could potentially go further with measures to compensate businesses, which are already suffering. Even under the guidance, advice and regulations that are currently in place, businesses are getting cancellations by the thousand, which has a serious financial impact. If there is to be another variant, which we cannot discount, it will add even more financial pressure, so that clarity is much needed.

We have spoken about the lack of clarity about additional funding from the UK Government. If there is additional funding, how do you envisage its being diverted to different parts of the health service?

Part of it would be to give more financial compensation to those sectors that have been hit, and hit hard. Again, I will not pre-empt what the First Minister will say in the next couple of hours, but even with the current position, there is no doubt that not only the hospitality sector, but the events and cultural sectors and others have been hit hard. If we had some greater financial certainty, we would be able to act in the way that we thought was in the best interests of Scotland.

I note again that that is not just an SNP or Scottish Government position; the Welsh Government, which is led by a different political party, has said something similar. The appropriate decisions for our countries should not be constrained by whether we get additional resource from the UK Government. It should be the case that we take the decisions that are in the best interests of health in Scotland and then the funding flows from the Treasury in respect of those decisions.

We are continuing to bolster test and protect and the vaccination programme as key foundation blocks in our fight against the virus. They are always important and they are being adequately funded. However, to give just one example, I note that we had to push the UK Government really hard for it to extend the contract for the Glasgow Lighthouse lab, which has done an incredible job. The contract was due to run out in March 2022 and we were getting anecdotal evidence that people were going to be looking for other jobs because they had no job security. The UK Government has now moved on that and extended the contract to September 2022, but we should not have to keep pushing it in order to get a level of certainty.

Given the emergence of the omicron variant, the impact that it will have on the recovery of the health service and the uncertainty around that, how do you see that spending around recovery being allocated?

There is no doubt that the omicron variant causes more difficulty. The emergence of a new variant that is more transmissible means that we are facing an even greater challenge.

As Gillian Mackay will know, when the first omicron clusters were found in the Lanarkshire area, we ended up in a position where entire departments in our acute sites in Lanarkshire were worried about staffing levels. They were able to cope, and I pay tribute to the management and the health board for managing the situation, but it looked really difficult and challenging at one time.

The emergence of a new variant not only has direct health impacts—although it has those, and we have to factor that into the recovery—but affects our staff. An exemption process in now in place for NHS and social care staff. However, if a staff member tests positive—and positive cases are increasing, as we see in the recent daily numbers—that will still have an impact on the health service.

Paul O’Kane has some questions on social care and the national care service.

I want to get a handle on the figures in the budget. Can you explain the difference between the £1.6 billion, which is highlighted in the budget, and the £1.1 billion that is identified in the budget tables under “social care investment”? I am trying to understand why there is a difference between those two figures and what the actual spend is.

I will have a look at the tables that you are talking about and give you an explanation.

The in-year transfers from the health portfolio to local government are grouped together within the budget as “social care investment” and the detailed elements are then set out in the level 4 budget tables, which are available on the Scottish Government website—that accounts for the £1.1 billion total. The £1.6 billion is the overall package of investment in social care and integration, which comes from a combination of funding that has been baselined in health boards and local government and from further in-year transfers from the health portfolio to local government. That is why there is a seeming discrepancy between the figures, but perhaps we could make that a little clearer. That is my reading of it.

That is correct. The £1.6 billion represents all the money that is passed from the health and social care portfolio to social care; about £500 million of that has either already been baselined in local government settlements or as part of an NHS board settlement that will pass through to integration joint boards. The £1.1 billion represents the transfer that will be made in-year. That is the reason for the difference between those two numbers.

It would be useful for further scrutiny if the committee could have more detail on that in writing.

I want to ask about the structure of the national care service. We are still going through the responses and the structure is not yet finalised in respect of the proposal to create community health and social care boards to replace IJBs. Does the cabinet secretary think that many of the issues that have been experienced with financial accountability and leadership in IJBs will be solved by creating a new structure?

That is a good question. First, I would say that there is no fait accompli. As I have said to the committee before, I am not sitting here with a master plan of what the national care service will look like and then expecting the consultation process to fit in with my thoughts—far from it. We are genuinely interested in the analysis of the responses, of which we have received a considerable number.

We also want to ensure that we do not create a system and then try to fit people into it, but that we create a system that fits around individuals. Financial accountability is hugely important, not only for us as decision makers and policy makers, but for the individuals involved. I will not be the only MSP who has had to fight on behalf of a constituent because they have not received a package of care for a loved one or relative and their fear is that that has been more to do with cost and finances than the actual needs of the individual.

11:45  

Again, I emphasise that nothing is concluded yet on the structure that we will end up putting in place—it may be that we will create community health and social care boards. However, financial accountability and leadership, which Paul O’Kane mentioned, have to be central to the creation of a national care service, whatever structure we end up putting in place.

Paul, do you have another question or can I move on?

I have just one more question, and I will segue to the subject of pay for social care workers. During the budget process, the finance secretary said that she felt that the 48p increase was fair and “pays carers for their labours”—I think that that was the expression she used. Does the cabinet secretary agree with that? Does he feel that that is an acceptable pay increase for care workers?

Paul O’Kane uses the 48p figure—I appreciate that if I were in his position, I might end up doing the same. However, if we look at what that pay increase means for an adult social care worker over the course of a year, it is not to be scoffed at. We are talking about just shy of an additional £1,000 a year. That is not the only pay increase that we have introduced as a Government or that I have introduced as health secretary. It comes on top of an additional pay uplift from £9.50 to £10.02, which of course was then increased to £10.50.

As we continue to be in the budget process, if Paul O’Kane believes that funding should increase social care workers’ pay to £12 or £15 an hour, for example—I am not sure what his current position is—we would have to find that within the allocated budget and such increases do not come cheap. I know that Paul has previously called for an increase to £12 per hour; that would cost £420 million per annum. If we took it to £15 per hour, it would cost £1.3 billion and, once improvements to terms and conditions were factored in, it could cost up to £1.6 billion. Those are not small numbers.

I absolutely take the point that our social care colleagues—those in adult social care in particular—need to be recognised and valued and that is why we have ensured that they get a pay increase and a pay uplift. When it comes to any addition to that, let us have that discussion but let us be up front about where that money would come from.

We move on to questions on preventative spend from Evelyn Tweed.

It is good to see a focus on preventative spend in the budget. How is the Scottish Government ensuring that there is a joined-up approach to spending and outcomes across portfolio areas?

That is probably the most crucial question that we are dealing with at the moment. This Government has progressed the preventative spend agenda for a number of years. It was core to the Christie commission report, which is as relevant today as it was when it was published.

We can do everything that we want to do in health but, if we operate in a silo, we will not make the difference in people’s lives that we want to make. We have to make sure that we are working with our colleagues—which we are—across the education, social justice, justice, housing and economy portfolios.

The work that the Deputy First Minister does in bringing us together, at least weekly, with a laser focus on, for example, child poverty targets, helps us to work in a way that is even more collegiate than was previously the case. That will both help us as decision makers and have an important effect on outcomes for those who have, regrettably, fallen through the cracks between the various systems and been passed from pillar to post, which is not acceptable. Good joined-up working is taking place between various portfolios.

We have heard about all the pressures on the NHS, and we are in the midst of another wave of Covid. How can funding for preventative spend measures be protected?

In all honesty, I think that those two aspects are linked. We can help people through Covid with the various spends that we have already put in the budget. Vaccination is an example. We know from the data that vaccine uptake can be at its lowest among those in the most deprived areas. When we deal with preventative spend by focusing on child poverty and early intervention, that can help our vaccination efforts not just in the current pandemic, but in ensuring that we are prepared for whatever the next pandemic might be. It is important that we do not see those two aspects as distinct and separate; I know that you do not.

With regard to protecting spend, it would be fair to say, looking at our budget in detail, that it delivers on the commitment to direct 50 per cent of front-line spend towards community health services and progresses our commitment to increase primary care funding by 25 per cent. We have a good basis on which to build. I agree that, with regard to current pressures versus what are seen as preventative measures, it is difficult to get the balance right, but I try not to view those two aspects as distinct and separate. Our investment in preventative measures will also help us to deal with the pandemic.

We move on to talk about shifting the balance of spend, with questions from Emma Harper.

At previous meetings, the committee has taken evidence on shifting the balance of care and moving spend to be more preventative, moving the focus away from hospital settings and more towards the community. The Scottish Government has committed to shifting the balance of care so that at least 50 per cent of front-line health spending takes place in community health services. That commitment is in the budget. Do we now need to be more ambitious, or is 50 per cent adequate for what we are planning?

I like that question from Emma Harper—it is fair to throw down the gauntlet in that regard. If we are already getting there, are we challenging ourselves enough? In my view, it is a positive that we have got to where we have.

The purpose of the target is to make changes on the ground and to underline the Scottish Government’s focus on shifting the balance of care where that is possible, while ensuring that we have in place appropriate support for hospital-based services. Nobody would say that—[Inaudible.]—which is an important point. I know that Emma Harper has personal experience of this area and understands the issues very well. We will continue to review the appropriate portion of spend.

To go back to my previous comments in response to the convener, once we do some further work on the medium-term financial framework and get further details, we will take that into account. In general, however, Emma Harper’s challenge to us is fair, and I will absolutely reflect on whether, if we are already meeting the 50 per cent target, we should be looking to be even more ambitious.

Sometimes all these budget lines, top lines and different figures just get thrown out there. I am interested in the idea of £15 per hour for care persons. That is what a band 5, three-year university-trained staff nurse makes. If we were going to make a challenge to move or increase that spend, that puts another burden on workforce planning, and that would be a concern for me. I am suggesting that social care staff should be supported and educated to have clinical expertise and progression, but £1.6 billion is an interesting figure that you have given us—if such a measure were to be taken—for a £15 per hour salary. It would be interesting to hear your additional comments on that.

I do not have much to add, although every single person around this virtual committee table will be in the same space when it comes to all of us valuing the role that social care workers have played throughout the pandemic. Dare I say that it should not have taken a pandemic for people to realise just what a significant and important role our social care workers play. Saying that is one thing; rewarding them appropriately is another. In Government, we have a good track record. In the past 12 months, we have increased their pay, effectively from £9.50 to £10.50 per hour, and we are putting up the appropriate finance and funding for that.

I fully appreciate that there are members across political parties who will say that they want us to go further. If that is the case, we will obviously engage with those budget discussions with the Cabinet Secretary for Finance and the Economy, but you must be able to tell us where you take that money from—perhaps from other parts of the health service or social care. Emma Harper is of course right that that could have a knock-on impact on other parts of the workforce, which we have to factor in.

I am always up for having this conversation on what more we can do to reward our social care staff. Let us do that based on figures and based on what is available in the budget. Let us have a realistic conversation about where the money would have to be taken from if other parties want us to go even further.

Emma, are you content to let me move on to the subject of mental health?

I had one more question, about progress towards increasing primary care spend by 25 per cent—I think that the Government has a commitment to increase primary care spend by 25 per cent. I make that my final question.

Yes, we do. Looking at my tables, I see that we are at about 6 per cent. That is a good first step in that direction. You are right: we have that commitment, I would be confident of meeting it, and that is a good step in the right direction.

We can now move on to the subject of mental health spending.

Good morning, cabinet secretary. First, I will quickly praise NHS Lanarkshire for all its hard work.

Moving on to mental health, I appreciate that, with NHS boards and integration joint boards delivering mental health services, tracking spending can be a bit challenging, particularly for things that are outwith the health sector itself. I have a couple of questions on that. First, what evidence is being gathered to understand the impact and effectiveness of the additional spend? Secondly, how does that influence future funding decisions—for example, the balance between adult services and child and adolescent mental health services?

Those are both good questions, and they are intrinsically linked.

I agree with Stephanie Callaghan’s opening remarks about the job that NHS Lanarkshire has done. It has not been without its challenges. Indeed, there are a number of challenges that NHS Lanarkshire often faces, given its geography and the pressures that it is under. It has coped admirably well. As you can imagine, we are working with NHS Lanarkshire very regularly to see how we can get it de-escalated from the highest level of escalation, which it is on at the moment.

12:00  

Stephanie Callaghan makes a good point about the effectiveness of the interventions and of the money that we spend. Any funding that we allocate is delivered against really clear criteria. The recipients of the funding have to report on its impact and on the outcomes that we agree. We have on-going regular engagement with stakeholders around the use of resources to deliver outcomes and what the risks may be. There can be unforeseen risks in a funding application that cannot be accounted for when it is received.

As the member probably knows, we have committed to refreshing our long-term mental health strategy. That work will build on the evidence of success that we have seen from interventions and on engagement with stakeholders and—crucially—people with lived experience, to identify what the future priorities will be. In turn, that will help us to know what our funding priorities should be.

The second part of Stephanie Callaghan’s question was also really good. It was about the balance between adult services and child and adolescent services. The first thing to say is—my goodness—what an impact the pandemic will have had on all those services. That is not to say that there were no challenges before; I readily accept that there were. I will not be the only MSP on this call who had a constituent who was in need of and on the waiting list for CAMHS. That list was far too long—I am not going to pretend otherwise—but there is no doubt that the situation has been exacerbated by the pandemic.

Our mental health transition and recovery plan, which was published in October last year, reviewed the priorities. An additional £120 million recovery and renewal fund was allocated to support the delivery of that plan, and decisions on its use were based on an assessment of proposals, set against those priorities, that was carried out in discussions with key stakeholders.

It is difficult to get the balance between adult services and child and adolescent services right, but that is something we are continually looking at. Making sure that we get that balance right is part of our NHS recovery plan ambitions, but it will require significant investment.

During the committee’s evidence session on perinatal mental health, we heard evidence from mums about the critical role that third sector organisations are performing locally. Their expertise is a lifeline as far as mums are concerned. In that evidence session, third sector stakeholders expressed concern about the fact that they are losing some of the local specialism and expertise that makes a really positive impact on the ground in local mental health services. How can more secure long-term funding be provided to support the delivery of mental health services by third sector organisations in community settings?

It is really hard. I concur with everything that Stephanie Callaghan has said. As you would imagine, I see every day—from a local MSP’s perspective, let alone from a health secretary’s perspective—the value on the ground of the third sector organisations and partners that Ms Callaghan refers to.

As the Cabinet Secretary for Health and Social Care, I want to make it absolutely clear that we value third sector organisations not only through our words but through our deeds. Our 2022-23 mental health budget will increase by 6 per cent on the 2021-22 figure, and, this year, we have allocated a greater proportion to support community and third sector projects. That includes £15 million for grass-roots community groups via our communities mental health and wellbeing fund, to tackle the impact on adults of social isolation, loneliness and mental health inequalities.

On certainty for the future, I do not doubt that an ask that I get is one that every committee member gets, which is the ask for a multiyear budget. The Cabinet Secretary for Finance and the Economy has laid out some of the groundwork for how she might implement that for future years. That might provide a longer-term, sustainable funding outlook for third sector organisations in the future. We are not at that stage yet, but it is an ambition that the Government has.

We will move on to alcohol and drug services.

Earlier, I mentioned the Audit Scotland report that said that the Scottish Government needs to be more proactive in showing where and how the money has been spent in the budget in general. I am looking for support and commitment on that in relation to the importance that we are all giving to tackling drug-related deaths. Will the Scottish Government commit to publishing regular information that shows us the granular detail of how the money is being spent?

In principle, I have no issues with that. I can look at what we publish at the moment, to see whether it would meet your expectations, and we can have a discussion about that.

In my letter to the committee, I referenced in some detail alcohol and drug partnership income and spending for 2021. We intend to publish the information once the analysis is complete. We will, of course, provide the committee with that publication. It will provide a level of detail on the income and spending of local alcohol and drug services, including what is provided in addition to Scottish Government funding.

If that does not provide you with the level of detail that you expect, I will be open to having a further conversation about how we can provide that.

We are just looking to get a sense of the consistency across the country. That is a theme that we hear about at all committee meetings, because of the variances that happen.

In the budget, there is a £1.2 million increase in direct Scottish Government spending on the alcohol and drug policy. How does that relate to, and come together with, the commitment to an additional £50 million per year in this session of the Parliament? I am just trying to get a sense of what the relationship is. Perhaps Richard McCallum would be better placed to answer that question.

I am more than happy to bring in Richard McCallum in a second, but, to be absolutely clear, that funding is in addition to the £61 million reducing drugs deaths budget, which includes the second tranche of £50 million of additional funding as part of the commitment for £250 million over five years from 2021-22. It is specifically aimed at supporting an additional response to our collective challenge on drug deaths.

The increase of £1.2 million in funding on alcohol and drugs for 2022-23, to which you referred, brings the total budget to £24.4 million. That includes investment in an alcohol harm and treatment policy team to deliver our alcohol priorities with Alcohol Focus Scotland, Scottish Health Action on Alcohol Problems and the Scottish Alcohol Counselling Consortium. It also provides funding for specific alcohol services that will be delivered to support the Simon Community Scotland to deliver a pilot managed alcohol programme.

That funding is in addition to the £61 million reducing drug deaths budget. I hope that that is clear. Richard McCallum might have something to add to that.

No, you have covered it. This is the second year of the £250 million over the session of Parliament, which is £50 million each year. It is covered in the 2022-23 budget.

As I said earlier, every party in the Parliament is—[Inaudible.]—tackling this and we really want to ensure that that additional funding is breaking through and getting down to where it needs to be. How will the additional spending be targeted to ensure that it is used effectively? How will we measure that impact? What are we looking at to ensure that the money that we invest has the desired impact and that it saves lives?

There is a slew of regularly published statistics—on which I know Ms Webber will keep a close eye, as we do—that will demonstrate whether we are making progress on that policy area, on which we all want progress to be made. Monitoring and evaluation will be at the heart of what we do. The Scottish Government works closely with our alcohol and drug partnerships to monitor the delivery of the national mission, which is what it is. Any organisation that receives funding for drug services will always provide regular reports on outcomes.

We will also work with public bodies that are vital in relation to that work, such as Public Health Scotland and Healthcare Improvement Scotland, to understand the bigger picture on delivery. Local interventions and the work at a local level will be really important, and officials monitor that, but we must keep an eye on the bigger picture. We will use that data to inform future funding decisions.

We will, quite rightly, be held to account on how we spend the money and on the difference that it is making. I expect that Ms Webber and all parliamentarians will ask questions to ensure that the Government uses the money in the most effective way possible, given the nature of the crisis that we are dealing with.

Emma Harper has questions on sport and active living.

I am pleased to be asking about sport and active living. We know that, during the first lockdown, people getting out for their daily mile or a walk was really important, including for their mental health. There is a proposal in the budget that investment in sport and active living will double to £100 million by the end of the parliamentary session, which is really good news. How will the additional funding for sport and active living be prioritised?

You are right to say that that is an important commitment. The issue has become even more important, given what we have been dealing with during the pandemic. We know that sport is good not just for physical health but for mental health, so it is important that we live up to the commitment to double our investment to £100 million a year by the end of this parliamentary session, which we intend to do.

How will the money be spent? It will allow us to rebuild capacity and resilience in the sector following closures during the pandemic. One cannot be unaware of the impact that the pandemic has had on sport. The impact has been felt at the local grass-roots level—for example, a daughter’s football club that she goes to on a Saturday, which might have been hit hard by the pandemic but not have reserves to reach into—right through to the biggest clubs in the country. That has been the case not just in one sport but across myriad sports. Sport has been affected by the lack of people coming through turnstiles, for example. I will not pre-empt anything that the First Minister will say this afternoon, but omicron is clearly causing us great concern in that respect.

We work closely with sportscotland and other partners to understand how we can best increase investment in physical activity and sport while ensuring that we also address inequality. To be frank, I note that some sports have been better at dealing with inequality of access than others; other sports and sporting bodies have a little bit more work to do in that respect.

I have a quick question about social prescribing. In the previous session, the Health and Sport Committee produced a report on the benefits of social prescribing and said that it is an investment, not a cost. Social prescribing is good for physical and mental health. What needs to be done, or is being done, to demonstrate that social prescribing is really good? How will that work provide evidence that social prescribing could benefit from further investment?

I am a great believer in social prescribing, as is the Government. I can check the evidence and evaluation that we publish on social prescribing and provide Emma Harper with more information.

Our programme for government includes the commitment that, by 2026, every general practice will have access to a mental health and wellbeing service, and that there will be funding for 1,000 additional dedicated staff who will help to grow community mental health resilience and to direct social prescribing. I think that that will make a massive difference to access to social prescribing. I know from the community link worker in my constituency, who does an incredible job of reaching out to the third sector and other support organisations, that help with social prescribing has made a big difference to a number of my constituents.

12:15  

I will look at what we have published or will publish on evaluating that and come back to the committee on it, via the convener. I agree entirely with the general point that Ms Harper made.

Sandesh Gulhane has a quick supplementary.

Kim Atkinson of the Scottish Sports Association said in her evidence to us,

“Given that culture is free, why is sport not free?”—[Official Report, Health, Social Care and Sport Committee, 30 November 2021; c 32.]

Do you accept that the cost of facilities can be a major barrier to participation? In hoping that you do accept that, I also ask what measures could be put in place to address it.

Dr Gulhane is right about that and I absolutely accept that cost can be a barrier. That is why in my previous answer I said that some sports have done well at making their sport more accessible, but other sports and sporting bodies have some work to do.

In the 2022-23 budget, we have increased our funding for sports and funding to support Active Scotland’s key outcomes of encouraging physical activity, developing physical confidence from an early age and so on. We are working very closely with sportscotland to make sure that it supports clubs in communities to offer a range of opportunities—for young people, in particular—to participate through community sport hubs. We are doing as much as we can to work through schools, as well.

Another example is that we are doing what we can to ensure that cycling is more accessible by providing bikes, where we can, to those who cannot afford them, and ensuring that they are available through community hubs, as well.

I will be happy to provide more detail, if I can. I agree with the premise absolutely; there are probably other areas that we need to fund. The cycling facilities fund is one example of what we have done. We also worked well with the Robertson Trust—which members will probably know—the Spirit of 2012 and sportscotland to deliver the changing lives through sport and physical activity fund. That has provided direct resource to sport and community bodies to widen access. It directly funded 17 collaborative partnerships of sport and non-sport organisations to deliver sport and physical activity in communities, with a focus on accessibility. Dr Gulhane’s wider point is one with which I entirely agree.

Thank you, colleagues. I am sorry to curtail the sport questions, but we have only 10 minutes left and two members have not asked questions yet. We will move on to questions about health inequalities from Carol Mochan.

Tackling inequality and poverty is, I believe, absolutely what we, as MSPs, are here to do. That goes for every portfolio. In almost every one of our evidence sessions we have heard from experts that in order to tackle health inequalities we have to tackle poverty. We have been advised that we have to be politically brave on the issue, so my question is this: are you prepared to be politically brave? Can you give us examples of what you believe we can do, and give us timeframes for that? It is very important that we know the timeframes within which we will measure outcomes.

I agree entirely with Carol Mochan’s assessment and her plea to every decision maker and policy maker that tackling poverty and inequality has to be the root of our mission in Scotland, because it touches on every portfolio in the Government. That is without a shadow of doubt.

I will not rehearse everything that I said previously about the good work that we are doing with the Deputy First Minister. However, to answer the question I say that the issue absolutely requires us to be politically brave and bold. We are up for that challenge. We have committed once again to doubling the child payment, which Scottish Labour had been calling for and has welcomed. There are a number of initiatives. Carol Mochan will know that we have committed to the family wellbeing fund for this session of Parliament. It is a significant investment that is designed to tackle child poverty.

There is no getting away from the fact that some of the investments will take the course of the parliamentary session to work. Of course, if we were able to meet our child poverty targets sooner, we would absolutely do that. Ms Mochan is probably aware of the detail of the child poverty targets, so I will not rehearse them. However, I give her the absolute commitment that regardless of whether we are in health, education, transport, housing or social justice, we are all absolutely at one on the drive to reduce child poverty. As the person who is responsible for the largest share of the Scottish budget by quite a distance, I am not unaware of my responsibilities in that respect.

We have heard evidence on the Scottish Government’s place-based community-led approach. Will you give examples of where that will make a difference?

Forgive me—I might have misheard. Did you ask about the place-based community-led approach?

Yes. It is referred to in our papers. Where could we use that approach quickly for people?

I suspect that Ms Mochan and I are at one in our belief in the importance of the place-based community-led approach. We will bring together a range of work that is focused on supporting local-level action to improve health and wellbeing and to reduce health inequalities with the long-term preventative focus that we have spoken about. We want to support health and social care services to work as part of wider systems to co-create wellbeing locally. That will enable our health and social care providers to play their role as anchor institutions in community wealth building.

There are many good examples of that, such as the joint pilot programme that started earlier last year—the link up the Gallatown project, with Kirkcaldy YMCA and NHS Fife—in which people are provided with training and placement opportunities in a local hospital. Many of them have gone on to secure employment. I referred to the development at Parkhead, which is another good example and will be our single biggest investment in a health and social care centre. The centre will bring together community services that are currently located in, I think, nine other sites. I have spoken to a doctor at one of them who is part of the deep end project, which brings together 100 general practices in the most deprived areas, and she can absolutely see the value of the work that we want to do on that.

Carol, can we move on?

I know that we are short of time, convener, but I hope that we can make a commitment to come back to the issue.

Of course we will.

We have final questions from David Torrance on linking the budget to outcomes.

Good afternoon, cabinet secretary. The national performance framework has nine indicators and targets for health. How does that fit with other performance frameworks, such as the local delivery plan standards and the national health and wellbeing outcomes? Which framework has the greatest prominence in setting budgets and spending decisions?

I think that I caught just the end of that question. In essence, the outcomes in the national performance framework are a consistent thread that runs throughout our work. They inform our planning across the board.

I think that David Torrance asked about prominence and how spending decisions are influenced. In that regard, the national performance framework goes through everything that we think about. Every time we make a spending decision, we look at the outcomes in the national performance framework and other frameworks, including those that David Torrance mentioned. The national performance framework is our guiding framework for the whole of Government. As I said, it is a consistent thread that runs through all our work and informs our planning across the board.

Given all the information that is gathered and evidenced in the national performance framework, has it ever led to definite and specific changes in the budget plans?

That is a good question. The national performance framework informs the budget. The impact on outcomes is, of course, considered when we make commitments. That, too, in turn informs our budget. We know that increasing health and care spending will directly contribute to the health and wellbeing of the nation.

The First Minister often talks about the fact that we cannot separate health and the economy—although people sometimes ask us to do so—because they are intrinsically linked. An increased workforce contributes to the economy, as does increased capital investment in health, which generates jobs and moves us towards our net zero goals. Our commitments to fair work and pay contribute to outcomes on poverty, and health has a role in each and every one of them.

The national performance framework sets our budget priorities. As I said in my previous answer, the framework is a consistent thread that runs through our entire consideration.

That concludes our questions to the cabinet secretary on the budget. I thank Humza Yousaf and Richard McCallum for their time.

At our next meeting, which will be on 11 January, the committee will take evidence from stakeholders as part of our inquiry into the health and wellbeing of children and young people. We will also undertake scrutiny of the draft mesh removal reimbursement scheme that the Scottish Government provided in advance of stage 2 of the Transvaginal Mesh Removal (Cost Reimbursement) (Scotland) Bill at our previous meeting on 14 December.

As this is our last meeting of 2021, I take this opportunity to send my and the committee’s good wishes to all our stakeholders who have helped us over the year. That concludes the public part of our meeting.

12:27 Meeting continued in private until 12:51.