Meeting of the Parliament

Meeting date: Tuesday, October 23, 2018

Official Report 1165KB pdf

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National Health Service (Performance)

The next item of business is a statement by Jeane Freeman on national health service performance. The cabinet secretary will take questions at the end of her statement, so there should be no interventions or interruptions.

14:52  

Today, thanks in large part to Scotland’s NHS, our people are living longer. That is good for all of us and for our communities, and it is a testament to our health service. However, it means increasing demand on our NHS, and that increased demand comes alongside the need to respond to medical advances, to effectively provide preventative care and to address underlying health inequalities. Those are not challenges that Scotland alone faces—they are challenges for healthcare systems across the world. However, they make it essential that we ensure that our whole system has the capacity, co-ordination and workforce to deliver the best care possible in every setting.

We do so in an uncertain environment, not least that of Brexit and the damage that it will do to our health and care services. The improvement plan that I am publishing today focuses on reducing the length of time for which people wait for key areas of healthcare. Simply put, some people wait too long to receive the care that they need. As with the recent financial framework, the plan’s investment is predicated on the assumption that the consequentials that the United Kingdom Government has promised will be delivered as a true net benefit to the Scottish budget. On that basis, the plan commits total investment of £535 million in resources and a further £121 million in capital over the next two and half years to make a sustainable and significant step change in waiting times. That is in addition to the £200 million that is already being invested in our elective and diagnostic treatment centre programme.

The increased investment will support reforms to increase capacity where it is needed; to reduce the numbers of people experiencing long waits; to reshape delivery to ensure sustainable performance against targets in the future; and to achieve the necessary balance of care to support that.

Over the next 30 months, we will deliver phased and decisive action, with clear milestones, to secure substantial and sustainable improvements to performance and to improve significantly the experience of patients who are waiting to be seen or treated. By October 2019, 80 per cent of out-patients will wait for less than 12 weeks; 75 per cent of in-patients and day cases who are eligible under the treatment time guarantee will wait for less than 12 weeks to be treated; and 95 per cent of cancer patients will continue to be treated within the 31-day standard. By October 2020, 85 per cent of out-patients, in-patients and day cases will wait for less than 12 weeks. By spring 2021, 95 per cent of out-patients and 100 per cent of in-patients and day cases will wait for less than 12 weeks, and 95 per cent of patients who are awaiting cancer treatment will be seen within the 62-day standard. In meeting those commitments, we will ensure that clinically urgent patients and those who are waiting longest are prioritised.

Our focus is on both physical and mental health so, following our programme for government’s £250 million package for mental health, the Minister for Mental Health will come back to Parliament later this year to set out specific actions and targets to improve mental health performance.

Achieving all of that requires not only work to address existing targets, but a whole-system approach that spans hospital, primary, community and social care to really increase sustainable delivery. Solutions will differ across the country and across specialties, but the drive for improvement will be national in scope, and it will require national action to increase capacity. That will build on our programme of investment in our new elective centres to provide additional capacity in order to meet additional demand and to protect the scheduling of elective care from the pressures of unscheduled care.

Through the improvement plan, we will accelerate delivery of the elective centre programme, including the operation of a new computed tomography scanner at the Golden Jubilee hospital, which will come on stream from 2019. The additional capital investment will include £17 million at Forth Valley hospital, which will include putting two new theatres in operation and putting additional magnetic resonance imaging capacity at the hospital by the middle of next year. That will be followed by elective centres in Highland, Grampian, Tayside and Lothian, and a second expansion at the Golden Jubilee. We will look to bring forward where we can the delivery dates on those important new centres.

Working with the Scottish access collaborative, we will focus improvements on those clinical priorities where pressures are greatest. Across all specialties, we will improve productivity through a sustained application of state-of-the-art technologies. One example of how we can use technology to improve performance and the patient’s experience is that, by this November, we will launch a scale-up challenge to mainstream the attend anywhere video consulting platform. Work is also under way to accelerate how artificial intelligence and automation can reduce waiting times.

However, those actions alone will not be enough. We must develop new models of care that support more sustainable services, alleviate the demand on secondary care and reduce the pressures on services that come from increasing unscheduled care. Community and primary care services are playing an increasingly critical role in ensuring that patients can receive more timely care closer to home. Our commitment to changing the landscape of local health and care was reaffirmed in the recent joint statement with the Convention of Scottish Local Authorities on health and social care integration.

Over the next year, we are accelerating the whole-system redesign of local patient pathways through integration authorities, NHS boards and clinicians. That will help to shape the front-door services of hospitals such as accident and emergency, thereby helping to further improve their performance and ensure that everyone gets access to the most appropriate care in the right place.

We are implementing the new general medical services contract and supporting the new primary care improvement plans so that local services can be redesigned to allow general practitioners extra time for appointments that require longer discussions and for building multidisciplinary teams.

At the same time, services will be improved through regional delivery and national boards’ plans so that services can deliver improvements on a cross-boundary basis. The wider public discussion and engagement on those draft plans will enter a new phase next month.

We know that this action requires a supported and skilled workforce. Although NHS Scotland’s workforce has grown for the past six consecutive years, there are key staffing constraints.

We are making significant investments in staffing. We have already delivered a three-year pay deal for all agenda for change staff, providing consolidated pay increases of at least 9 per cent over three years for all employees earning up to £80,000. We are creating 2,600 extra nursing and midwifery training places over this parliamentary session and are investing £3 million to train an additional 500 advanced nurse practitioners. The number of GP training places is increasing to 400 a year, and we are investing more than £23 million to increase the number of medical school places. Further, over this parliamentary session, we are training 1,000 paramedics to work in the community, which will help to reduce pressure on A and E services.

Those are some of the workforce improvements that we are making, and the improvement plan will build on them. Over the next three years, we will invest £4 million in domestic and international recruitment for GPs, nurses, midwives and consultant specialties with the highest existing vacancy rates. Further, we will develop a fresh approach by focusing activity to help address priority specialty areas that have global shortages, in areas such as psychiatry and paediatrics.

How we plan for our workforce is crucial. Our Health and Care (Staffing) (Scotland) Bill will introduce requirements to ensure the right level of staffing for the workload associated with patient need. Further, we are leading other United Kingdom nations by publishing a fully integrated health and social care workforce plan by the end of this year. That will set out how we will ensure that we have the right numbers of staff in the right place at the right time to provide person-centred, safe and effective care.

In acting to reduce current waiting times levels in key areas of care, our responsibility is also to increase the sustainability of our health and social care system. The successful future of that system is predicated on targeted investment and sustainable reforms. Patient satisfaction is high, our NHS workforce is at a historically high level and investment in our NHS is at a record level. All of that is a strong foundation for our work and for the carefully phased, targeted action that the plan sets out. Alongside the more than £850 million of investment over the next two and a half years, that represents decisive action that will deliver results for patients and for our NHS.

The cabinet secretary will now take questions on the issues that were raised in her statement. We have about 20 minutes for questions.

I thank the cabinet secretary for advance sight of her statement, and I welcome Monica Lennon to her position.

Every MSP will have been asked for help by constituents whose operations have been cancelled or who face unacceptable waiting times. For example, one of my constituents in Edinburgh who has severe hip problems was told in June that he could be waiting until next February just for an initial appointment with an orthopaedic consultant before he would be added to the waiting list.

We hope that the action that has been outlined will result in progress, but the fact stands that the treatment time guarantee that Scottish National Party ministers legislated for in 2012 has never actually been met. Today, in this statement, SNP ministers are publicly accepting that they have failed to deliver on past promises that were made to Scottish patients.

What is key is that SNP ministers understand that delivering a sustainable workforce is critically important. Today, the cabinet secretary stated her intention to create an additional 2,600 extra nursing and midwifery training places. Again, the fact stands that, in Scotland today, 2,812 nursing and midwifery posts are vacant, with 852 lying unfilled for more than three months, which is a 27 per cent increase on last year. Further, more than 4,300 nurses left the service last year.

Can the cabinet secretary outline what steps that are not included in her statement will look to address the growing workforce crisis that we have in Scotland? Does she understand that we need to stop the bleeding in our NHS before we put new blood into our NHS? What will she outline that will deliver a workforce plan for the future that is actually fit for purpose?

I thank Mr Briggs for his comments and his question. Parliament has my commitment that the action that I have outlined will lead to progress. That is why my proposals are deliberately phased and targeted.

The commitment that I outlined on additional nursing and midwifery places is a Government commitment. However, as Mr Briggs will know, we look annually at the number of training places that we need to put in place across a range of areas in our health workforce. In doing so, we take into account various factors, including expected retirals and the number of staff who wish to work part time. We take into account other factors, including additional commitments that we have made as a Government, not least in the programme for government, particularly in respect of mental health nurses. We now also have to take into account staff who we will lose or be unable to recruit because of impending Brexit.

We will look annually at that commitment to assess whether, based on all the data that we have, we need to increase it year on year. Mr Briggs has my assurance that that is what we will do. We will advise Parliament and the Health and Sport Committee on the decisions that we make on the 2020 intake.

I understand the importance of our workforce. I value them above all else, because without a highly trained, specialist and, most important, committed workforce, our NHS would not deliver the significant results that it does deliver, notwithstanding all the challenges that it faces. The challenges faced by our NHS in Scotland are challenges that are faced across the world. However, this Government is the only one in the United Kingdom with a plan to tackle workforce challenges. There are a number of plans, starting before recess with our medium-term financial framework and working all the way through. We have a plan, we have a commitment and I am determined that we will succeed.

I, too, thank the cabinet secretary for prior sight of her statement.

Scottish Labour will always welcome any additional support for the NHS. That support is desperately needed. Last week, an investigation by Scottish Labour revealed that, since 2015, there have been 1 million stress-related sick days in our NHS. Staff are at breaking point because this Government has mismanaged the NHS. All of us are grateful to the dedicated staff who work in our NHS. They deserve better than this, and so do patients. This Government gave patients a legal right to treatment within 12 weeks, but that law has been broken 150,000 times. Let us get this straight. Is it the Government’s intention to keep on breaking its own law until 2021?

I thank Ms Lennon for her question. I, too, welcome her to her new role and look forward to our exchanges.

It is not fair, accurate or particularly helpful to our staff in the NHS to use hyperbole such as we have just heard. According to our iMatter survey, there are pressures and strains on our health service, and our workforce absence level is higher than we would wish it to be. However, there is significant satisfaction among staff across all our health boards about their working conditions and level of involvement. They know, as I do—[Interruption.] If I could perhaps finish, Ms Lennon. They know, as I do, that there are pressures and challenges to be addressed. Indeed, the workforce plan and the plan that we are looking at today are the product of work with those very staff. I do not accept the hyperbole that is too often used. I am disappointed that Ms Lennon is not congratulating me on not abandoning the targets, which was a concern that I read about in this morning’s press. I have no intention of abandoning our targets and every intention of meeting them.

There are 11 members who wish to ask a question and 11 minutes left. If everybody is to get in, that means a minute for each question and answer. I cannot say it more bluntly than that. I have no doubt that Ms White will set an example.

As has already been stated, workforce planning and staffing are paramount. I therefore ask the cabinet secretary whether she believes that the implications of a no-deal Brexit will affect our ability to attract the specialist staff that are needed to realise the plan that has been set out today.

Of course, a no-deal Brexit would affect our ability to attract those staff, but any kind of Brexit deal that does not involve the customs union and other freedom-of-movement arrangements will impact on our health service, because even at this stage in the proceedings, we do not have agreement on mutual recognition of qualifications from the UK Government. That means that the health service could now lose staff who want to stay, yet we have not reached that agreement on existing qualifications at a UK level.

The UK Government is not extending the pilot programme for registration to families of healthcare workers, which will significantly encourage people to feel that they are not welcome here. The Scottish Government has been very clear about the welcome in Scotland, and today, with the Welsh Government, we have offered to pilot a programme of registration support that includes the families of healthcare workers.

Do any of the proposed changes to the current targets and indicators reflect Sir Harry Burns’s recommendations for a life-course approach to ensure more focus on prevention in our health system? Will the cabinet secretary assure members that the needs of children and young people in our pressurised healthcare system are adequately reflected in the plan?

I will answer the second part of Alison Johnstone’s question first. I give her the assurance that the needs of all children and young people in our population are reflected in the plan.

In my statement, I mentioned the work of the Scottish access collaborative. One of the tasks that I have given it is to consider in some detail the work of Sir Harry Burns on how we take forward the means by which we determine where our health service is successful and where improvement is needed.

However, that should not deflect us—I will not allow it to do so—from the work that we need to do to meet the targets that we currently are committed to as a Government.

The Government’s improvement plan suggests that we posted our worst-ever performance against the waiting time guarantee this September. Does the cabinet secretary recognise that the cruellest aspect of that is that every one of the 31 per cent of people for whom that target was missed will have received a letter saying that they would be seen within 12 weeks? Does she agree that it is time to review the management of patients’ expectations so that we can be up front with them from the outset about how long they will have to wait?

Personally, I would not describe it as reviewing the management of expectations. However, there is a need for significant improvement in how our boards communicate with those who are seeking treatment so that they are as up front with them as possible about what the board is able to do as we work our way through this plan. We will make sure that boards review the communication that they give patients, and make sure that they consistently communicate with individuals, rather than patients having to get in touch with boards to find out what is going on.

The cabinet secretary mentioned the use of the attend anywhere programme to allow virtual attendance for patients to speak to medical professionals, which is being utilised in a number of areas, including Wigtownshire in my region of South Scotland. Will the cabinet secretary set out when that will be rolled out around Scotland? Will it reduce the need for out-patient appointments?

We plan to commence the wider roll-out of the attend anywhere programme around the country in December. It is being implemented in a specific way to remove the need for some out-patient appointments and, in particular, to alleviate pressure on individual patients who might otherwise need to travel to meet appointments.

The pilot programme has demonstrated to us that there is a clear need to ensure that that opportunity is offered to patients where it is entirely clinically safe to do so. It is on the basis of the success of the pilot programme that we will roll out the programme from December.

The Health and Sport Committee reported that the Government has made limited progress in reporting budget allocation against the nine national health and wellbeing outcomes. Does the cabinet secretary agree with the committee that a greater link is needed between investment and delivering quality health outcomes? If so, how does she intend to address the lack of transparency?

I agree that there needs to be greater clarity about where our investment goes and how that links to quality health outcomes and our overall approach of safe, effective and person-centred care. With respect to this plan, we will make sure that members understand how the additional investment that I outlined will be used to deliver the plan’s actions. We are currently reviewing how we deal with those matters, and I hope to come back to the Health and Sport Committee and respond to the issues that it has raised in that regard.

The cabinet secretary will be aware of today’s press reports that a range of targets will be withdrawn. Given her comments, what will she do to reassure patients and staff that she has no such plans?

I say loudly and clearly, starting here, that I have no intention of withdrawing the targets and every intention of meeting them. I will say that here in the chamber, I will repeat it in any media commentary and it is very clear in the news release that we have issued. The plan itself speaks to that. We have no intention of withdrawing from the targets that we have set and that we intend to meet.

The cabinet secretary will be well aware that the well-respected economist Professor John McLaren has concluded that the NHS will face an annual black hole of up to £400 million, which will rise to £415 million a year in 2023. Does anything in this afternoon’s statement fundamentally change the above analysis?

I fundamentally disagree with the above analysis, and I will give Mr Stewart some of the reasons why. I will be brief and I will be happy to follow it up in greater detail. Mr McLaren’s reference point is a publication in May, which made assumptions about what a modernised NHS would look like.

A comparable figure in the financial framework is 3.5 per cent, which is supported by the King’s Fund, the Nuffield Trust and the Health Foundation and is consistent with that of the majority of independent analysts. It is based on anticipated demographic pressures that are greater than those that were included in Mr McLaren’s assessment. I disagree with his assessment. Before the recess, in our medium-term financial framework I set out clearly the challenges, what we are doing to meet them and the further work that is required in that regard.

The cabinet secretary mentioned the Golden Jubilee hospital twice in her statement. Can she say any more about the investment there and what the increased capacity will be?

The increased capacity in the Golden Jubilee from March 2019 will include an additional CT scanner, which will provide an additional 10,500 images per year; an increase in throughput of cataract operations undertaken in the mobile theatre, to provide another 600 cataract operations; an additional 600 endoscopies between last month and March 2019 and an additional 1,200 for the financial year 2019-20; additional general surgery activity, providing 250 more procedures; and an additional 4,000 ultrasound scans per year from 2019-20. In addition, NHS Forth Valley and the Golden Jubilee have undertaken at least two shared appointments for ophthalmology consultants, which is an example of working across boundaries and working in a new manner that is better fitted to the needs of our patients.

Thank you. If everyone can be brief, I will get in the last three questions. I call Annie Wells, to be followed by Mary Fee.

The percentage of medicine places that are accounted for by Scotland-domiciled students has fallen to its lowest level in 10 years under the SNP, at just over 50 per cent. Is the cabinet secretary satisfied with that drop? Can she say how many of the additional 400 GP training places that were promised in the statement will be for bright young Scots from all walks of life?

The Scottish Government is funding those additional training places. Therefore, those who are eligible for the funding will receive those places, provided that they meet the medical schools’ requirements.

In addition, given that we are on the subject of additional medical training, I should have mentioned the Scottish graduate entry medicine programme, which is a postgraduate programme that has just begun in the University of Dundee and the University of St Andrews. The programme is an additional measure that offers specific training that is targeted at GP work in remote and rural communities. Fifty-five students are on the programme and, if it proves successful, we will want not only to continue it but to increase its size. The programme will target specific areas in which there are particular shortfalls in GPs.

I call Mary Fee, to be followed by Stuart McMillan. I ask you to be brief, please.

We know the impact of delayed discharge: 43,913 bed days were lost in August and there has been a 15 per cent increase in the number of patients whose discharge has been delayed due to issues with their health and social care package. Integration joint boards—

That is not briefly. Just get to your question, please.

Integration joint boards were set up to reduce delayed discharge. Can the cabinet secretary give a realistic date for when that might happen?

We have a number of joint boards, as the member knows. Providing a realistic date that encompasses all such boards would remove their capacity to meet local demand, which is why they are there in the first place. At that point, I would probably be accused of providing central diktats, so I will not provide a date.

I am sure that the member paid careful attention to what I said about whole-system reform and the critical importance of increasing the pace of health and social care integration, as I have been doing since June, in order to ensure that we alleviate the pressures in our secondary and tertiary care system. We are working on that in consultation and jointly with local authorities, as is appropriate. Labour members certainly claim to want us to take that approach, so I would have thought that they would applaud it.

Can the cabinet secretary indicate what steps have been taken to update ophthalmic services so that more can be done in the community rather than in acute settings?

A number of steps have been undertaken on ophthalmic services. We now have a range of opportunities that suitably qualified and clinically approved opticians and optometrists can undertake, specifically relating to longer-term maintenance and support for people with macular disorders and other eye conditions. We are looking not only to continue those opportunities but to roll them out, because that is part of the primary care development plans that each integration joint board has now submitted.

Thank you. We have managed to get everybody in, but we have taken a little time out of the next debate because there was time in hand. Members still need to make their questions tighter.