 Good morning and welcome to the first meeting of the Health and Social Care and Sport Committee 2024. I've received no apologies for today's meeting. The first item on our agenda is to decide whether to take items 5, 6, 7 and 8 in private and whether to consider in private at future meetings a draft report on the National Care Services Scotland Bill. Our members agreed. Thank you. The second item on our agenda is to take evidence from the Cabinet Secretary for NHS Recovery, Health and Social Care as part of the committee scrutiny of the Scottish Government's budget 2024-25. For this morning's session, I welcome to the meeting Michael Matheson, Cabinet Secretary for NHS Recovery, Health and Social Care, and Richard McCallum, director of health and social care finance, digital and governance from the Scottish Government. I invite the cabinet secretary to make a brief opening statement. Good morning, convener, and thank you for your invitation to discuss the Scottish budget with you today and what it means for Scotland's health and social care services. It includes funding of more than £19.5 billion for the continued recovery of the NHS health and social care system. This budget also provides an uplift of which exceeds front-line Barnett consequentials. It means that resource funding for health and social care has more than doubled since 2006-07. Despite this investment, the system is under extreme pressure as a result of the ongoing impact of Covid, Barnett, Bexar and also inflation. The UK Government spending decisions have also resulted in hard choices with greater efficiencies and savings needing to be made. However, investing in Scotland's NHS is non-negotiable for this Government. The budget settlement gives our NHS a real-terms uplift in the face of UK Government austerity. Crucially, it includes more than £14.2 billion for our NHS boards with an additional investment over £1.5 billion. The budget also supports investment in excess of £10 billion for the NHS pay bill, rewarding our dedicated and skilled NHS staff in recent years. There is more than £2 billion for social care and integration, delivering on our programme for government commitment to increase social care spending by 25 per cent over this Parliament two years ahead of our original target. It provides an additional £230 million to support the delivery of the pay uplift to a minimum of £12 per hour for adult social care workers in third and private sector from April 2024, representing a 10.1% increase for all eligible workers. We continue to invest in quality community health services to support our priorities relating to prevention and early intervention. This includes investment of over £2.1 billion for primary care and supporting spending in excess of £1.3 billion for mental health. We will continue to work with partners to address the challenges this settlement brings and to take forward the reforms that are essential for delivering a sustainable health and social care system while delivering high-quality services. I am happy to respond to any questions that Members have. Thank you very much, cabinet secretary. We are going to move straight to questions. Thank you, convener, and declaration of interest as a practicing NHS GP. Good morning, cabinet secretary, and thank you for coming today. From the opening statement and from what we've heard and seen you say previously, do you feel you have adequately resourced the Scottish NHS? I don't think you would ever get a cabinet secretary for health if you would say that they wouldn't want more resource to invest in our health and social care system. I think in light of the very challenging budget settlement which we have, we've achieved the best possible outcome we can for the health and social care budget. But notwithstanding that, there will be efficiencies and savings which will have to be made in order to live within the budget settlement which we have and the growing demand which we face as well. I think it's the best outcome we can achieve in very challenging financial circumstances. However, there will still be continued challenges for the health and social care system, even with this budget settlement. What would your top three priorities be with the budget that you've set out? What are the three things that you would want and expect come the end of our year into next year? Well, continued investment in our NHS recovery, including in prevention, with a particular focus on primary care. Also, continued investment in mental health services and to make sure that they are meeting the needs of citizens right across the country. Also, continued investment within social care to ensure that we are doing everything we can to give greater resilience to social care, particularly in recruitment into the workforce that are critical to supporting our NHS. Thank you. On those three priorities and in your opening statement, you spoke about mental health. Is it not true to say, though, that there is a 1.6% reduction in real terms in your budget for mental health? The reality is that, since 2000, about £1.3 billion is invested in mental health services. Of the central funding that comes from the Scottish Government, about £290 million of that comes from the Scottish Government. That has actually doubled since 2020-21. Over the course of the past two to three years alone, we have doubled that level of investment. We have maintained that going forward, despite the difficult financial environment that we are operating in. That has allowed a very significant expansion of mental health services in Scotland. We want to sustain that and maintain that going forward. Over the course of the last couple of years, there has been a huge increase in the level of investment that we are putting into mental health services. We have seen a significant reduction in mental health across our country. We have also seen significant increases in CAMHS waiting times for our children. The longest wait in Glasgow was 37 weeks for somebody to be seen. This reduction surely will impact and harm mental health. No, I do not agree with that. I think it would be unfair to suggest as though waiting times in CAMHS services have not been reduced. There has been a significant reduction in waiting times for CAMHS, particularly the build-up that is developed over the course of the pandemic. Staff across our children and adolescent mental health services are working really hard to address these, and we have saw some significant reductions in waiting times. Of course, where there continue to be extended waits, that is not acceptable. That is why work is still being taken forward in order to address that. If anyone looks at the mental health budget over the course of the last couple of years, they cannot avoid the fact that it has, in some cases, more than doubled, which is allowed for a very significant expansion of services and an increase in capacity in those services, which we are now seeing the benefits of in terms of the reductions that we are achieving in CAMHS services overall. I recognise that there remains challenges within the delivery of mental health services, but notwithstanding that, very good progress is being made and a sustained increase in investment we have made over the course of the last couple of years is making a difference. In your top three priorities, you spoke about NHS recovery in your opening statement as well. Do you feel that you have put a budget in place? Should we expect to see significant reductions in improvement in A&E waiting times and significant improvements in waiting times for procedures? Let us look at where we are in terms of A&E at the present time. We have saw an improvement this year compared to where we were last year. We are continuing to work with boards in order to help to sustain further improvements going forward. You will be aware that one of the major challenges that we have around performances around A&E is the flow from A&E into the hospital. A significant part of that is caused by delayed discharges. Despite the fact that around 98% of all discharges from hospitals take place on time, that 2% has a significant impact on flow into the hospital from A&E departments. We have saw a reduction in the number of delayed discharges at this point this year compared to where we were last year. One of the things that I want to make sure that we are doing in the course of the year going forward is very intense work around looking at what more we can do to reduce those delayed discharges because we know that is a critical part in helping to support the flow into our hospitals. A second element of work that we are taking for is trying to help to reduce the level of demand that we see presenting at A&E departments. For example, last week, the work that has been taken forward, not just last week, but over the course of this winter, the work that the Scottish Ambulance Service is doing through their integrated clinical hub is reducing the number of people who have to be conveyed to A&E departments as a result of the investment that we are making into that service. So, there is what we are doing to help to improve these things, but demand is very significant, but I believe that there is still further progress that we can make, and I am determined to make sure that over the course of the next year that we will do that, and we will continue to make sure that we focus in any areas that we know will help to improve the performance that we get in our A&E departments and across our unscheduled healthcare systems. So, making progress, but certainly much more to do, and a real determination to make sure we do that. My final question, Cabinet Secretary. We now have regularly over a thousand drug-related deaths, and we seem to be going backwards in the care that we give to people with drug dependency. There has been a reduction in real terms in the budget. What is your commitment to that figure and to reducing the number of deaths, and how do you expect people to do that with less money? Well, we gave a commitment to increase investment over this parliamentary term of some £250 million into tackling the twin challenges of drug and alcohol misuse, and we are on track to deliver that and to sustain that level of investment. One of the areas that we are keen to see further growth in is around the provision of rehabilitation services, and I know that work has been taken forward in order to achieve that, but the commitment we made to make sure that there was sustained investment in both drug and alcohol services has been taken forward in this budget to make sure that we continue to see the progress that we need to see in the delivery of these services in order to improve outcomes for those who suffer from drug and alcohol misuse. If you look at where we are in terms of funding overall, so in terms of funding in drugs policies increased by some 67% since 2014-15, so there has been a sustained period of increased investment, but we gave that commitment to making sure that there was an additional investment of some £250 million in order to support our drugs and alcohol mission, and that is a commitment that this budget builds upon in delivering. Emma Harper Thank you, thanks, convener. Good morning, Cabinet Secretary. Good morning, Richard. I'm interested in just questions about the NRAC formula and the review. I know that it's specifically calculated to help support remote and rural places, so are you able to give us an update on the undertaking of a review of NRAC and timescales, for instance, of when we might expect to have the review in front of us? Okay, so in this budget we have allocated an extra £31 million in order to help to ensure that all boards are within 0.6% of NRAC parity. The largest chunk of that goes to Lothian and Fife as part of the £31 million going forward. The term for the group is the technical advisory group on resource allocation, which has met three times so far and is drawing together a range of work in order to take forward the review of NRAC. I should say that this won't be a quick process. Any funding formula that has to be changed or developed will take a lot of detailed work to be taken forward. I don't know if Richard can say a bit more on how that work is progressing, but the group has already started commissioning the data and information that they require in order to look at how they could adapt to existing NRAC formula. I don't know if Richard can say a bit more on how that work is progressing. I split just two or three things. First, I think that the NRAC formula is still valuable in terms of the information that it provides for us. As the Cabinet Secretary has said, it is a really important mechanism by which we allocate funding, given that it does take into account a wide range of both population and health factors into the allocation. The technical accounting group that is looking at this has met, as Cabinet Secretary has just said three times already, and is going to continue that work over the course of 2024 to bring this work forward to review by the Scottish Government later this year and potentially into 2025. The commitment has been for this to be reviewed over the course of this Parliament, and that is what we, as officials, are certainly committed to doing. As I say, over the course of the next year, we hope to be in a position to bring forward any changes that there might be. As I say, I think that even in its current form, the NRAC formula has a value and a role to play, and it is about making sure that any refinements we make are properly reviewed and scrutinised, and that is what we will do. I am just thinking about NRAC, just because we are doing a health care inquiry into remote and rural health care right now in the committee, so I am sure that it will help informers in our inquiry. Good morning, Cabinet Secretary. Talking a bit more about health boards, I am interested to understand what processes are in place. Firstly, to do comparisons between health boards, because clearly there are different challenges in different part of the countries, but there is also an awful lot of common challenges, so to understand which health boards, if you like, are better at performing and more efficient at delivery, and then what mechanisms are in place for health boards to learn from each other, from best in class and role at best practice. Yes, and I will bring Richard in on some of the work that we do with boards around looking at how we can do shared learning. We have a formal monitoring process for all of our boards in terms of performance, not just in terms of key targets, but also around financial management as well, and we also conduct our annual review process for each of our boards to evaluate the progress that they are making, and there is an in-year review for them as well. I think one of the challenges that has been around a long time, and I call this when I was previously a junior health minister, was trying to make sure that where there is good practice in one part of the country that we see that being replicated, there are parts of the country. It is not a challenge which is peculiar to health, it is a challenge within the public sector overall, and it is always a source of frustration to me that for a country of five million people that we struggle at times to make sure that that happens, when good practice is established that it sticks as well. We have a number of different mechanisms that we seek to do that through, so one is that we bring our chief executives together on a regular basis where we will focus in in particular areas of challenge and where boards have taken new approaches to share that practice. We do the exact same with chairs, so I meet with the NHS chair boards, chairs of the boards every six weeks or so, where again we have an opportunity to focus in in some key areas where there is good practice or challenges in certain areas in order to try to help to encourage that practice. We are also making much greater use of the Centre for Sustainable Delivery, which is based at the Golden Jubilee, so that is a unit which was established that looks at key areas where there are opportunities for efficiencies and improvement in service delivery and then takes that forward with individual boards, can model it on the impact of having an individual board if they were to deliver this in a different way and it can also go and induce specific work on individual boards as well. So the Centre for Sustainable Delivery, I think over the course of the next couple of years, will probably be the key mechanism that we will use to try and get greater consistency and also to make sure we are getting better adoption of good practice where it has been identified and also bringing in new ideas into boards. I will ask Richard maybe to say a bit more on some of the stuff we do around finance with their boards, but there is a whole range of work we try to take forward in encouraging the adoption of good practice where it is established in one board in the country. Your challenge in terms of the different positions across NHS Scotland is the right one because whilst all boards need to make savings and all boards would recognise some of the financial challenges that they face, not all boards are in the same position financially. Even if we take last year 22-23 as an example, 17 boards reached financial balance, five didn't, and so there is a formal mechanism, as the Cabinet Secretary said, where boards haven't been in that position to scrutinise and challenge the issues and areas of focus that the board will take forward to address the financial challenges that they have. More broadly, we do work very closely with all of the health boards, yes through the chief execs group but also through directors of finance and other forums. I think one of the key things from our perspective, we've developed a list of almost 15 key areas, and I'd be very happy to share that with the committee, but it takes a range of areas like, for example, effective prescribing and looks at the data from across the country. Sometimes the variation will be understandable and warranted and there will be good reason for that, often it won't be. That's given us a mechanism by which we can, well firstly, we expect boards to look at all 15 areas and assure themselves that they're doing all they can in each of those areas, but also from a government perspective for us to look at that and challenge and scrutinise where boards might be off track. Another area is in relation to supplementary staffing and I suppose going back to Ms Harper's point, there might be certain parts of the country where it is more necessary and required and needed than others, but nonetheless it's important that we can see that variation across the country and put that appropriate challenge and scrutiny where necessary. Okay, so health board management are well aware of where they sit in those 15 league tables and who's best and who they should be learning from? Oh yeah, it's very clear to the system. Thank you. I think my point is probably linked just to what has been said previously by my colleague and it is around this sort of sustainability of health boards and where we think you know who's required to work together. You noted that there are in my paper said four but five health boards that are indicating that they're having financial pressures. So in terms of sustainability you know what are the key actions that yous are working on together? You know if I was to say what are the three things that yous are working on together with the health boards that are on that escalation framework particularly around stage three? Yeah, so we've got a couple of I think five health boards that are at stage three just down in terms of the escalation process. I think it's maybe just important to emphasise is that the providing tailored support to boards which are experiencing some specific financial pressures is not new. So this is a mechanism that's been in place and used over the years at various points so it's not new clearly though we're in a very challenging financial environment so we've got boards that are under extra pressure. So a couple of areas that Richard just touched on I'll get him to say a bit more on some of these. So one is around staffing in terms of how they manage your staffing, the use of agency staff against bank staff and also recruiting staff as well and the second area is around prescribing as well. There are marked variations in prescribing between different boards and the costs which are associated with that so why we might essentially procure a lot of these drugs within Scotland at prescribing variations can have an impact and the chief pharmaceutical officer is doing work around making sure that we do as much as we can to try and get greater consistency of that as well because that again can address issues around cost associated but do you want to say a bit more Richard than some of the other work that we're taking forward and in order to help to support around financial sustainability? Yeah so I think there's broadly sort of three or four areas that we're working most closely with boards and I should just say on the five boards I mentioned that was on the outturn in 22-23 we're obviously still working through the current financial year with health boards but yeah we would I mean the major spend areas for health boards are obviously in relation to workforce and medicines and so there are two key areas that you know we we are taking forward that work we've mentioned the work around supplementary staffing and effective prescribing that's absolutely key and actually making sure that there's good practice in all of those areas where there are opportunities to switch from from pattern to drugs to generics and other opportunities like that then it's really important that there's that clarity in in terms of how that's taken forward I think as well as that it's drawing on work that can be done by the national boards as well so we have NSS that takes forward a lot of work on behalf of NHS Scotland and again if I take the example of procurement and actually good practice in procurement prescribing would be an area where they can support but there are other areas as well making sure that where there is an international approach to certain services that that's taken forward and considered and and all boards are expected to to to play into that process and work through that as well as indeed are they to to work with one another to identify best opportunities and best practices I was just updating Mr Mickey okay thank you I've just got a couple other points that gets raised at the committee and quite a lot this one is about the way in which sentiments are made and sometimes multi funding you know like multi-year funding is helpful and we hear that a lot in other sectors but we have heard this in committee and how are you pleased to be able to offer that to some of the the boards do you mean as in multi-year budgets yeah yeah sorry yeah so look I think we we tried through our I think it was our it was a medium term financial framework that we published back was it 2022 where we sorry yeah it was a spending yeah the spending review 2022 we tried to set out more of an indication over a three-year period the problem is that we only get an annual budget myself so I don't know what next year's budget is going to be so it's the real challenge is the the way in which the fiscal environment operates in the UK we work on an annual basis which means it's very difficult to give a commitment into what will happen next financial review when you don't even know what your budget is going to be so I agree with you I think that if we could get into a cycle where we were able to provide a much clearer indication over a three-year period it allows organisations to plan more effectively it's probably a much more efficient way as well in which to manage services if you've got that certainty but the principal challenge we've got to be able to do that is that we we're working on an annual budget ourselves so we don't know what our budget will be the following year which makes it almost impossible for us to then give commitments into a following financial year and we don't know what the outlook will be but I agree with the premise and the point that if we could do that we should do it but that would require fiscal change at a UK level not to give us that type of certainty over a three-year period yeah I mean I think you're right it's for organisations to be able to predict even that they're likely to have similar or ongoing increases in funding my last point really is around the NHS boards and the sort of three three percent recurrence savings you know like what discussions have you had with the board if any around realistically are they you know is that sustainable for them yeah well boards have been expected to make recurring savings for some time now so would you call it so it's not new to them so they're well practised in this a key part to is to try and make sure that there is a focus within boards on efficiencies so we discuss that with boards on a regular basis both at an executive and non executive level to make sure that they are looking at expenditure to achieve efficiencies where they can as well and that's no different in this financial year and in some cases it's it's more important than ever given the very tight financial environment which we're operating in but I do think it's important given the level of expenditure that boards have got which is over 14 billion pounds worth of taxpayers money that we do apply targets to them to make sure that they're driving efficiencies in the system where they can remember that's not money that's lost to the system that's money that's used within health care but it ensures it allows us to make sure that we're getting as much efficiency out of the investment we're making as possible and I think it's important that boards are given that challenge just finally just one wee bit to boards indicate if they've reached the the sort of point that that is becoming more difficult for them or are they saying to use that they feel that they can continue to to work at that level three percent I think I think most boards would say look we prefer not to have to do it if they could but I think in terms of driving efficiencies in the system I think it's important that we do set that challenge for them it's a bit like you know the four hour wait target you know A&E if you were to take that away actually I think it would probably cause more problems it drives some of the system so I think the three percent is a way of driving them to make sure that they are looking at their expenditure and to see where they can be more efficient is well so notwithstanding the challenges that go with achieving that I think it's an important challenge that we put to them and we make sure that we hold them to account for that given the huge amounts of public sector or taxpayers' money that they're responsible for spending each year that they're doing it as efficiently as effectively as possible very much thank you and I thank you thank you just to clarify on that three percent recurring savings point can you unpick what that actually means because clearly the budget in cash terms and in real terms is increasing to health boards yet we're talking about three percent recurring savings I'm assuming that so and I kind of like for like and then additional stuff is where the other money is going but how do you kind of unpick that so we know what that three percent is actually referring to yeah so I mean in cash terms that's probably somewhere around 300 to 400 million to give you an idea of just the sort of scale of that and I think that's just recognising that that boards there will be inflationary pressures for boards on some of the areas we've already mentioned if I take drugs as an example we know in secondary care the inflation that there is around drug costs is rising you know a significant rate so it's important that boards do have a focus as well as all the additional investment that is that is provided by the government that there is that eye to that that savings target as well so normally in addition to the half a billion uplift that boards have received there would be that expectation that they would be making savings as I say three percent somewhere in the region 300 to 400 million normally so I'm not real understanding that you're giving the health boards additional money in cash terms and in real terms every year so when you talk about a three percent saving how does that manifest itself in the numbers so it's an increase not a saving yeah so we don't take that three percent off them that's how do you measure how do you know they're making that saving if they're you're just giving them more money so so we we get reports regularly every month on on board savings and savings plans but what we what we allow is for that money not to to be returned to government but it's retained within the system so any saving that the board makes they keep that within their own system to invest in the the priorities that that they will have in that system but but but we do have that oversight of where those savings are are being made okay you need to be pretty hot on the process and the numbers to make sure that that's all all absolutely narrow because it's easy to lose the numbers there yeah oh you know the declarative reporting the areas that boards are focused on I mean as I say that's something that we get regular and detailed reporting on to understand so the implications that effectively are that not only are they getting a 1.7 percent increase in real terms they're also getting a three percent increase through those recurring savings yeah which is actually an excess of health inflation effectively that's correct so if if you if you can achieve more of your savings in a sense that's better for you because you can invest more locally okay I just want to unpick if you look at the the budget you go down obviously level four is a loss we go on it's got health boards individual lines just interested understand a wee bit below that specifically round about the issue that gets raised from time to time round about is the health service over managed how much of the money gets spent on bureaucracy admin management cost etc etc versus how much is spent on the clinical side or on medicines so do you have clear visibility on that by health board those numbers that are that are available for for analysis yeah so we don't publish that at the time of the budget but on an annual basis there is the NHS cost book which is which is published for the for the previous year and that sets out in in detail what spend across a range of category lines so the next update from Public Health Scotland who published that data is going to be in February and that will set out in in detail where the the total spend that we've set out in the budget where that is going by individual line okay so we've got visibility on that I'm interested to see that and just finally on this to what extent are health boards cooperating with each other to look for shared services areas where they can combine back office etc etc to take cost out there so it's probably fair to say it's variable so there are some boards that have got joint commissioning of services which which they take forward on a they take forward on a on a plan basis where they think it's in their mutual interest to to do so we've I've recently we've given them a voluntary option where they can choose to do it if they they wish to do it and there's a mechanism for them to go through if they want to do that so if it's backroom function stuff it's like HR stuff etc doing that now I shared commissioning basis I'm moving it to a mandatory basis okay so where they're going to be required to do it there are there are probably a range of boards that could actually be looking at doing more around sharing some of their backroom functions and and we're we've already indicated to boards that we intend to move that into a mandatory space that it's now required for them to do that and that will be around things like HR types of payroll aspects that could be that could be managed on a joint basis thank you good morning cabinet secretary good morning how can the twin pressures of increased pay and demands for additional staff be balanced in the NHS and in social care within constraints of the budgets so in terms of in health we could the key to the health services is its staff so and it's important that we provide them with the financial recognition for the important role they play which is why we've taken forward the agenda for change commitments that we have given a commitment to the last financial year and also the way in which we've engaged with them around pay negotiations as well and that inevitably creates financial stress in the system and financial charms of the system as well but it's critical we do that because they are key to the delivery of their health service and that will have to be met within the existing budget allocations that have been set out in the 2024-25 budget and in social care with the additional investment we've put in which is over 800 million pounds in the last couple of years a key part of that is helping to address the issues of pay within the social care setting because we know that's a major challenge in recruiting into social care and we know that the delivery of social care is critical to the performance of our NHS as well so if we want to have an effective functioning health and social care system we need to make sure that we are providing resources where we can to help to pay staff for the important role they have and that's the approach that we've taken around pay negotiations both in health and social care and through the agenda for change programme. Around higher NHS pay what effect is that going to have on services if non-staff budgets need to be reduced to fund that increased pay offer? Sorry I missed the first part of your question The increase in NHS pay what effect will that have on services if it's to be funded staff budgets need to be reduced from non-staff resources? You can look at this a number of different ways so is the yet places challenge on the budget in paying staff and increasing the pay for staff but I don't grudge on that at all so giving an important role which they have that means that some of the other areas investment they might want to make are not going to be possible because we're increasing the pay for our staff however the impact of not paying our staff and not settling these types of issues is also very costly so both in terms of the financial cost and also the service delivery cost that's associated with them so if we weren't able to get settlement around some of these pay deals we would inevitably be facing things like industrial action and we know that has a very significant financial cost to the NHS so for example if you take the industrial action between your doctors in England I think it's estimated that it's custom you know over a billion pounds alone because of all the additional things you have to put in place to try and cover during the course of industrial action alongside that something like you know 1.2 million appointments being cancelled that then has a service delivery impact so we have to recognise that if we don't invest in our staff and we don't try to resolve these types of issues in a co-operative fashion that they can be hugely disruptive and very costly to how the NHS is able to deliver its services and the approach we've taken is to try to help to resolve these matters in a fair and reasonable way with the employee side but of course that then has a financial impact on wider service delivery and it may not be able to expand services in the way in which you would wish to given the financial environment in which we're operating but notwithstanding that it's you know investment in services the way you do that is by investing in your staff and I see pay up lists for staff as being an investment in our NHS. Thank you Ruth Maguire. Thank you convener good morning cabinet secretary and Richard I'd like to stick with social care budget please and forgive me you did mention some of this in your opening but I think it's worth getting clarity for the record can you tell us what the total level of spending on social care planned for 24-25 is let us know how that current position compares to what the Scottish Government inherited in 0607 and can you also tell us how that increase compares to Barnett consequentials received place? Yeah I can give um so the total budget for um for social care in the 2020-24-25 is just over £1 billion so if you take from the budget figures that I've got here so um so if you look at where that was in 2022 2023 it was £879.6 million so that's a further 200 plus increase which is a reflection of the additional investment we're putting in to increase pay within social care. I don't think we've got a figure where I can take you back to what we inherited here I would have to come back to you with that because it goes back to 2006-07 budget and are you able to tell committee how that increase compares to the Barnett consequentials that the Scottish Government received? I think in terms of well in Barnett consequentials well you can see in terms of in the health side is that there is a barn larger I don't think we get a Barnett consequential for social care so there's no direct barnett consequential for that in the way in which there is for health. Okay okay it can be a bit challenging to get clarity around the social care budget just because of the way the money flows between government health and local government. Scottish Government committed to increase spending on social care by 25 per cent over the course of this parliament can you remind committee of how progress has been made on that? Well we've already met that target so we're ahead of schedule on it so by I think two years is it right so we're ahead of it so it was within this parliamentary term and it's already being delivered. Obviously touched on in one of your other answers just the importance of social care in terms of the whole system and when we talk about them separately but they are intrinsically linked particularly from the perspective of patients and good quality services in the community often prevent hospital admissions particularly on scheduled ones can you share with us how the Scottish Government agree makes decisions about the appropriate balance between money going to social care and money going to other areas of health? Yes so there's a couple of different routes that money flows into social care so there's the funding that we provide to local authorities who will invest in some health boards will invest in social care provision alongside some of the central funding that we provide as well for social care lards around things like the pay uplift funding which we're providing so the scale of financial demand and health is different from that of social care so obviously healthcare gets to the line share of that but we have made a very deliberate decision to make sure that we increase investment in social care and in particular in staff in social care in order to try to increase its capacity or sustain its capacity because we know it's under very significant pressure. I think one of the things that will be absolutely essential as part of a reform programme going forward is the ability to deliver a national care service where we can ensure there's a greater consistency of approach on how social care is being provided and how that aligns alongside the NHS much more effectively because we can see variation across the country which have an impact on how services are received by individuals in social care and require social care support and also that impacts on the performance of the NHS as well so I think going forward we will need to see even further investment in social care but we'll also need to see service reform and I think a national care service is going to be critical to helping to ensure that we see a much more consistent approach on how social care is delivered and being provided in the country and how that also aligns much more effectively in helping to work in support of our NHS so further investment and also service reform are going to be critical. Will that service reform just as we're thinking about budget will that make it easier to move budgets to move resource from you know into the community? I don't know if it will make it easier I think what it will give us is an ability to be much more much clearer about the outcomes that we're looking to achieve for that investment as well or for the level of public expenditure goes into social care and to seek to achieve much more consistency. I think for things like staff there's benefits to it so for example on things like collective bargaining which they can benefit from which I know is an important issue for trade unions as well so I think in terms of making it a more attractive place for folk to work I think in trying to get greater consistency of how services are delivered how that better aligns with the needs of helping to work with our NHS. I think the creation of a national care service is going to be critical to supporting is achieve that and also I think that will help us in being able to get greater consistency of how that funding is being used and to ensure that it's being used to achieve better outcomes for individuals that need to make use of these services in a way that we don't have at the present moment. Okay thank you. I'm very weird that there are still many members who haven't had an opportunity to ask any questions yet and I'll come to standard school for a very brief supplementary. Thank you convener. Cammel Secretary we were speaking about the national care service and you've said that there's a billion pounds on the social care budget so could you tell us how much of this budget line relates to the nts and how much relates with her adult social care funding? It's about 15 million pounds as to the national care service. Thank you. I'd like to ask a question about reinforced autoclave aerated concrete if I may please so it's not clear exactly how many properties are affected and what the remedial action will be so are you able to give us an idea of cost based on surveys that have taken place to date and how long the remedial action will take so over what period thank you. So are you not aware of what the health facility scotland had been taken for? I think it was 254 so properties that were initially identified in the desktop exercise they all had there the original risk assessment they all had that work carried out before the end of the year with intrusive survey work carried out and they published the online on each of those projects. So could you share that with us so are you aware of the cost and the timescales for remedial action? So for the vast majority of them it's 250 forward identified as priorities I think actually only one property actually had to be vacated and actually it was in the process of being vacated anyway on that and the others only require I think the vast majority of them only require additional monitoring so that's all publicly available so health facility scotland have that on their website and also each individual health board published information on that as well what they were doing once they completed that work I think as I previously stated before the end of last year I think it's at the end of November that work could be completed and it was completed on time is that there were some additional sites that had been identified that weren't previously known some of them are not facilities that are directly owned by the NHS but they may be for example GP services et cetera which they were also now taking forward a programme of carrying out survey work for them as well which I think included it because I think it was about an art in our hundreds of buildings but that information is all publicly available so in terms of cost are you able to put a figure and a timescale for remedial action? Well the the the works didn't identify any remedial works remedial works that required other than the normal routine maintenance work that boards would take forward from the work that was carried out last year so some of that rather moving to a survey rather than a survey being carried out every three years to be carried out every year instead so and it details the type of things that they should be taking forward some of them but there was no major costs were identified as part of the survey work that was carried out by health facilities Scotland okay just to confirm no significant costs and no significant remedial action there was no there was no significant works and there was no major disruption to services as well so in a few areas where there was what needed it was part of the normal routine maintenance work good thank you a second question so this relates to the capital investment budget so in in recent years the design and delivery of hospital infrastructure projects was beset unfortunately with delay over spend and and sadly an unthinkable tragedy as we saw in Queen Elizabeth hospital in Glasgow so i'm just looking at NHS Grampian and NHS Grampian has conceded that there are serious issues as we've discussed before with the design of water systems and ventilation for the Baird family hospital and the anchor centre and that has created and does create a significant pressure on the project budget and it's very difficult and they've shared as well it's very difficult for them to actually quantify the financial impact of that so my question cabinet secretaries can you confirm what headroom if any is available within the latest project capital investment budget for the Baird and anchor projects in order for them to reach completion so has that been has that been factored into the budget thank you so the the capital budget for the Baird and anchor is what was originally agreed so within the overall project so no extra money there's no additional capital or capital budgets been cut by the UK government by you know nearly 11 percent so or sorry 10 percent so um so in construction costs for projects that are already in delivery have also increased as well so um we're trying to use that as fairly and as reasonable as we can but there is um there's no additional capital available um because of the cut we've experienced uh alongside the the construction inflation that projects are facing as well so you see cabinet secretary you can imagine that's that will be extremely worrying that if a hospital has got major design flaws and there's no extra money coming that that there there are serious questions about delays to completion well um obviously it's a grampian project and we're taking it forward as a as a board um we'll provide them as we do through NHS assure with as much support and assistance as we can um to make sure they get these things right um uh and that they address any any changes which have to be have to be made but there is no i'm afraid there's no additional headroom within the capital budget given the given the cut that we've experienced from the UK government to our capital budget and the direct impact that then has on capital projects right across not just health but right across the Scottish government and uh any additional cost will have to be made within the project cost overall so you're in control of the budget and you're blaming the UK government no because we get our capital budgets depending on the capital allocation we get from the UK government they've cut our capital budget by 10% no further questions thank you so the consequence of that is that there is less capital funding available for investing in capital projects in scotland in top of that we're also experiencing very significant chances around construction inflation so some projects in some cases have almost doubled in cost um as a result of construction inflation which has been experienced over the course of the last year to 18 months as well so you've not only got increased costs for projects you've also got as a result of the UK government's decision to cut our capital budget less money to invest in capital projects that's a direct consequence of a decision that's been made by the UK government to cut our capital budget jillian mckay thanks convener and morning cabinet secretary um preventative spend is often difficult to track and quantify particularly when once it goes into um health board budgets as well as the health benefits from preventative spend often taking a long time to show up in population health data how does the Scottish government track and evaluate preventative spend and does the cabinet secretary believe that that data needs to be improved to further target preventative spend so there's a number of different ways in terms of we try to invest in preventive spend so normally around behavioural change programmes whether it be around alcohol and drug use or eating habits etc smoking all of which are all about preventing trying to reduce a to reduce some of the health consequences that we experience as a result of these challenges so we do that a lot of that's done through marketing campaigns also service delivery programmes that we fund the NHS boards for many of them will have targets and what they're set for for example on smoking cessation programmes and the number of people that they should be seeking to reduce so we're able to monitor the progress they make against these types of targets we also invest in areas for example we're taking forward some for example new innovations that we're taking forward for example around type 2 diabetes remission and also type 2 diabetes prevention programmes the digital dermatology programme vaccination programme bun cancer ai all of these are programmes that we use in order to try to help to do more in the preventive space through use of innovation how do we identify some of these things that we take forward we've got a programme called annual which is headed up with in partnership with the chief scientific officer to identify areas for investment in preventive spend that we know going forward that will have a significant impact in helping to improve outcomes and we do that as a wins for Scotland approach to identify what's the most appropriate areas for investment in new technologies in NHS Scotland to support preventive spend and we're able to evaluate those programmes as they are rolled out and as those investments are made as well so that combination of the programmes that we run that we evaluate through health boards for things like preventive healthcare issues alongside annual programme is targeting new innovations that we know can help to prevent ill health and improve outcomes for individuals and we evaluate what's the most effective route in which to make those investments and evaluate their impact as well that's great thank you a shift of preventive spend is sometimes difficult to do when there is acute need within the system and I was pleased that through the budget the consultation on a public health supplement has been proposed which is something my party have long backed does the cabinet secretary believe that measures such as these could help to drive preventative spend yeah I think so you know I know there's always an ambition to invest much more within preventive healthcare where we can and that's challenging when you're in a very difficult financial environment and given a very significant demand that services are facing as well but notwithstanding that where we've got the opportunity to do so we should and I think we've committed to exploring this around a public health levy over the course of the next year which I think would provide an opportunity if it was agreed for it to be introduced to see investment into other areas of preventive spend as well I think we should also recognise is that new innovation in technology can play quite an important part in some of the preventive approaches that we take forward which as I mentioned around some of the diabetes work that we can do that some of that new digital technology that we can use could have a real impact in helping to reduce some of the other side effects that people can experience as a result of diabetes and helping them to live healthier and we know that will then have a preventive spend in the future because of the benefits that come from that we know things like using things like AI and radiography can help to identify issues at an earlier stage as well and earlier intervention which would reduce further expenditure in the future so I think technology and new innovation can play a really important part in helping to make sure that we're doing more in the preventive space and any additional investment that comes through a public health levy in future years to support that would be very welcome and the cabinet secretary and I have had many conversations about vaping and the impact on on health and given how quickly novel products can affect health what impact does this have on preventive spend budgets and is the way we allocate these budgets flexible enough to adapt if novel products have an impact on health in the year so I'm not too sure whether we've got enough flexibility in it because it goes back to a point that where the carol one of whom was making as well which was around some of the challenge we have around giving organisations budgets to take forward programmes over the course of a year that then has to be adapted and changed in year when we will learn the information about something that's coming on to the market so I think maybe we should be think more about I'll have to think more where there's more we could do to allow some flexibility in that but for example around vaping we've saw over the course of the last number of years now how that's a sector that has just growing exponentially to quite a mart degree and it has there's not just health issues as environmental consequences that go with that and the need for stricter regulation around these issues and we've obviously got the joint consultation which we're taking forward just now with the other four nations in order to look at what further restrictions we should be put in place so there's no doubt in mind in my mind that there is a need for proactive action in the part of government here in a preventative space and I think there is a I'll take away the point around flexibility in year but I'm just conscious of some of the challenges we have in the way in which we fund the organisations if we were to look for them to adapt that in the course of a financial year. That's great. Thanks, Emma Harper. Thanks convener, just to pick up on what Julian Mackay is asking about preventative spending, the diabetes related stuff in the last session of parliament and I was interested to find that you know if we invest more in prevention you know we would then mitigate a lot of NHS spend like we spend £772 million on obesity related conditions in the NHS so if we can upfront prevent type 2 diabetes or reverse it or help manage weight loss so and I'm looking at the budget for public health Scotland it's it was 56.3 million last time and 57.5 million is what's proposed for this year so that's an increase and public health Scotland are doing currently doing a whole systems approach to diet and healthy weight but it's not just the health budget that's impacted because social care like a social care budget is looking at tackling poverty which is part of what leads to poor diet for instance so is there work that is taken forward or happening where it's not just specific in one portfolio that other portfolios help inform what action is being taken forward for instance so what I'm suggesting is that it's not just up to the health budget to manage some of the challenges that we have in tackling poverty and managing weight there's other portfolios that help support that as well so I think if you look at the issue of some of the consequences of lifestyle that result in ill health it's very often NHS that's dealing with the consequences of these but there are other services that could do more to help to prevent these issues from arising so the investment we're making in areas such as for example in early years in my view is absolutely critical in helping to improve the outcomes for children evidence shows that to be you can see that internationally is that early years intervention is much more effective in helping to improve outcomes for for children and young people not just when they're children and young but in later life as well investment in issues tackling child poverty so through the child Scottish child payment are examples that will help to reduce some of the risks that are associated with child poverty that can have an impact on an individual's health and their long-term well-being the best start programme again are all measures that some of which are health but some of which are portfolio areas that can have an impact in helping to to improve some of the health outcomes that we have in the future having said all of that you know if you do look at the disease tree if you look at something like you know if you look at something like obesity and all of the different branches that come off that from you know cardiovascular through to respiratory through to through to diabetes and all of the consequent things that come from that neuropathies etc if you tackle some of the root areas much more effectively you can help to head off some of the other consequent health complications that come from these conditions so i suspect that you know you probably recognise that tackling things like obesity is one of the critical areas that can help to reduce demand on cardiovascular diabetes some of the respiratory issues and everything that can go with that which would have a preventative benefit in the future in saying all of that biggest risk that we have to trying to tackle some of these challenges i think particularly around health inequalities that we're experiencing is that you know the two key areas are moving in the wrong direction mortality rates are increasing and health inequalities are widening they have been for over a decade now largely as a result of austerity so you can see all the evidence demonstrates that so that as you reduce the social protection system then the impact that then has on increasing mortality rates and increasing inequalities gets greater and we're being going through that over the course of the last 10 years which is why that data is going in the wrong direction there are certain things you can do to try to help to mitigate some of that but there is very clear to me is that austerity we've had for over 10 years and the austerity which we're experiencing at an even greater level just now will result in people dying prematurely because of the impact that will have on the social protections that people are dependent upon reducing and i believe that's probably one of the biggest public health challenges which we face going forward so if there's one thing i would do to try to help to tackle some of the health inequalities and the consequent problems that go with it it would be about tackling economic policy around austerity which would have the biggest impact in helping to reduce some of the very marked inequalities which have been expanding over recent years okay thanks and i forgot to remind everybody i'm a registered nurse with the NMC i should have said that at the beginning thanks thank you Paul Sweeney thanks cabinet secretary mr mcallan for for coming in today just wanted to come back on the detail of mental health expenditure in particular it's the government's long-standing target to achieve a 10 front line then it's just expenditure on mental health services by the end of this parliament current allocation is around 8.8 percent which represents a actual expenditure shortfall of 1.8 million pounds could the carrot secretary please talk through how he intends to achieve the target by the end of the parliament's under the current curve so you're right yes so it's about 8.8 percent of expenditure at the present moment i hope by the end of this parliamentary session we'll have a 10 percent that will be dependent upon future budgets and availability of finance to do that it would certainly be our intention to do so but as i mentioned earlier on there's been a very significant uplift in mental health expenditure since 2020 2021 where we've increased our level of investments more than doubled in terms of Scottish Government investment in this area so it's still our ambition we're at 8.8 percent and we need to look at whether budgets in future years are going to be able to allow us to continue that increase to achieve a 10 percent the current actually highlights the the longer term increase in mental health expenditure the target was set by the government of 10 percent and it has stalled it's certainly stalling this year and it's going backwards in real terms um do you view that as a high risk of not achieving this target is this an area where you've got a kind of red flag against that particular target and saying that's something we're going to be challenged to achieve by the end of the parliament it's a reflection of a really difficult public financial environment which we're operating in so where we're not able to make all of the increases that we would like to do so um we have as i mentioned made a very significant increase over the course of the last couple of years but sustaining that going forward in the present financial environment is really challenging um so we've sought to protect it as best we can uh in order to sustain the investment we've made over the significant increase in investment over the next of the last couple of years uh but whether we'll be able to increase that further is going to be dependent on budgets in future years and at the stage you know i can't you know if if the present approach to public finances continues it's going to be really challenging to do that uh given the pressures on public sector budgets right across government okay there's an area of particular concern obviously highlighting the as mentioned earlier the real terms cut to drug and alcohol budgets i think it's down 1.6 percent this coming financial year that represents a real cut of 100 000 pounds or so might seem quite minor but it has having a direct effect for example on the proposed closure of the two turning point 218 service in Glasgow next month um due to the funding settlement from the integrated joint boards in Glasgow um of just 650 000 pounds down from 1.3 million that was described by turning point is unworkable thus it's closing down potentially affecting um you know the impact women's mental health recovery people are suffering from addiction issues and potentially also interacting with the justice system also cognisant of preventative spending and need to rehabilitate people um Would the county secretary consider engaging directly with the Glasgow city council and the health and social care partnership they have to find a way to potentially salvage the service which could potential have a big impact on the healthcare budget i know it interacts with justice but it does have a cross cutting effect on healthcare as well Will the Secretary respond to that on it? It's not something that sits directly within my portfolio. That's a fair point. But would you impatsh the stakeholder with clear impacts on the health care system, potentially make representations to find a way through this with your colleague? I'm more than happy to ask the Just the Secretary to respond to the issues that you've raised given it's a just a slid area, rather than being a health-specific area on that. Maen nhw ddim ddim yn gweithio i'r unigwyd, i ddweud 250 miliwns i ddweud y twinio ar gyfer alcohol, ac mae'r ysgolion yn cael ei ddweud o'r parolau. Felly, mae'n ddigon i ddim yn cael ei ddweud. Mae'n ddweud o'r dweud o'r ddydd o'r ddweud o'r lluniau a'n gallu ei ddweud, ac mae'n ddweud o'n paes i'n ddweud i'r ddweud i'r ddweud. wych yn gobeidio'r bwysig o'r syniad sydd wedi'i chyfnodd y ddechrau yng Nghymru'r r contaminated plwyddiol yn y teimlo i fy Penedig fel gyda ni nhw'n bwysig iaith am ni'n ei gwbod maen nhw'n bwysig, ac mae'r ddaf yn gweithio'r bwysig iaith jaith yn ei gwyddiad y pwysig iaith, nid o ffordd sydd wedi'u ddwygen i mi fearsu bobl sy'n bwysig iaith, ac mae'n rhai ei ffordd os ydy yn rhaid o gwyddoedd yn siaradau i chi gydweithio'r blwyddiol? neu wrth o'irian, oedd y 218ません. Yn uwch, gennymau yn Maegu Llanhwg a Llanhwg yn fel rydych chi'n hyrwng gweithio lŷnfynol iawn. Ond, mae hyn yn cael ei gwleol yn cael ei maen nhod sy'n oser oŵn ei bod yn gwneud o'r hwnnau i gyfath, yn cysylltiadau ysgolwr i hynny, o'r llwy i gwybodaeth lleol y bydwyd yn ei chylen, yn butwch fel gydy'r cyfathol? Roedd yn fawr o grei'r hefyd creu gyda'r hefyd sy'n gwybod y cwerthu gweithreidwyd ac mae wneud wedi cael ei gwybod yna rhai yn hyfforddi. Mae'r dweud i ddim yn dweud i'ch ddiwrnod hefyd. Felly, y bod yn adreciaeth, mae'n lighterwyr â y su. Mae'r informant yn gweithreidwyr â ddweud o'u awfodyn o'r ddweud creu. Mae'n dweud i ddweudio ar y bowd, ac mae'n dwi'n dweud i'r rhywbeth yn dweudio ar yr oedd y rai. Mae'n adreciaeth eich dweud o'r llun. Felly, we would certainly want to raise that with a board, but in terms of day-to-day operations, it would be a matter that's the responsibility of the individual board to deal with. If there's a wider systemic issue, I would certainly be concerned about that, and I would want to take action around that if there was a problem in a board. That's great. I'm much appreciated. Thank you. Can I thank the Cabinet Secretary and Richard McAllum for joining us this morning? I will briefly suspend the meeting to allow for a change of witnesses for the next agenda item. Our third item of business today is consideration of an affirmative instrument, anaesthesi associates and physician associates order 2024. The purpose of this instrument is to allow the statutory regulation of anaesthesi associates and physician associates by the General Medical Council. It provides a framework for AA and PA regulation and establishes the powers and duties in relation to the GMC, including the autonomy to set out the detail of its regulatory procedures in its rules. The Delegated Powers and Law Reform Committee considered this instrument at its meeting on 9 January 2024 and made no recommendations in relation to the instrument. We will have an evidence session with the Cabinet Secretary for NHS Recovery, Health and Social Care and supporting officials on the instrument. Once we have all our questions answered, we will proceed to a formal debate on the motion. I welcome to the committee Michael Matheson, Cabinet Secretary for NHS Recovery, Health and Social Care, Rachel Coutts, Scottish Government legal directorate, food health and social care, Nigel Robinson, unit head professional health regulation chief nursing officers directorate and Scott Wood, unit head sponsorship and infrastructure health workforce directorate all from Scottish Government. I invite the cabinet secretary to make a brief opening statement. Thank you, convener. This statutory instrument is first and foremost about patient safety. Safe effective and person-centred practice is the driving force behind how we deliver healthcare in Scotland and patients have right to know that they are being cared for by professionals with the appropriate level of assurance and accountability. Convener, these roles have been practising across the UK for 20 years now and we cannot delay the regulation any longer. With numbers and skills continuing to grow, we must introduce consistent UK-wide standards supported by meaningful sanctions when those are not met. This is also a significant stride in the road to meaningful reform of the regulation of health professionals, something I know that several of us around the table today will appreciate. In bringing these devolved professions into statutory regulation, this order also brings the general medical council within the competence of the Parliament and therefore this committee for the first time. The regulatory landscape is complex and unwieldy, with each regulator operating within their own legislative framework. There is too much inconsistency and bureaucracy, which restricts the ability to swiftly adapt to the evolving demands on our health services without recourse to legislation. Convener, this order is the culmination of years of collaborative working between the four governments of the United Kingdom and multiple public consultations. As such, it is the first step towards a more modern and flexible model of regulation, establishing the first generation of a framework that will ultimately apply consistently across the health professions. It requires the GMC to set up a register and to put in place processes around education and training, fitness to practice, offences and appeals for these roles. However, I must acknowledge the pejorative commentary around these roles in recent weeks both across both social and mainstream media. This relentless negativity has been detrimental to our physician associates and anesthesia associates, and I hope that this statutory regulation will promote respect for their contribution to our healthcare system. It is important to note that, while each of the governments agree that regulation is necessary, decisions on their utilisation within NHS Scotland will be taken by Scottish Ministers and based on what is best for the people of Scotland. Our wider approach to the development of this workforce will be informed by our newly established maps implementation programme and overseen by a programme board made up of a range of key partners. We expect that board to meet for the first time next month. Thank you, convener. Of course, I'm happy to respond to any questions the committee may have. Thank you very much, Cabinet Secretary, for that opening statement. Before I begin, can I refer members to my register of interests and that I hold a bank staff nurse contract with Greater Glasgow and Clyde NHS, and I'm a registered mental health nurse registered with the NMC? Am I correct in thinking that these regulations follow on from a 2019 agreement with UK Department of Health and Social Care, along with discussions with all the other devolved health departments, about the GMC taking on this rule of regulation of PEAs and AAs? It's part of a long-standing piece of work that we've been taking forward with the UK Government in back in 2019. The then Cabinet Secretary for Health and Sport signalled an agreement with the UK Government that we should bring forward legislation to regulate both AAs and PEAs. However, there were issues around the wider regulatory framework, which was part of that discussion, which was about carrying out quite a significant review of the regulation of healthcare professionals, and it was then viewed that actually trying to do all at the one time was not going to be effective. It was too complex, and the decision was made to take the PEA and A aspect regulation separately, while the wider piece of work around health regulation was being considered separately. That's a separate piece of work, which is why this has been brought forward as a standalone order. Thank you for that clarification. I welcome your statement with regards to some of the commentary that there has been on healthcare professionals working as AAs and PEAs. Can I ask the cabinet secretary how he responds to some of the claims that having the GMC as regulator will add to confusion between doctors and PEAs and AAs and how that can be mitigated? I've heard some of the commentary around this. I don't subscribe to it, so we have a range of different health regulators that regulate a range of different professional groups. The idea of the GMC being able to take on the regulation of PEAs and AAs, in my view, I don't think will cause any confusion so long as there is a very clear regulatory body responsible for dealing with any issues relating to PEAs and AAs. I've heard some of the commentary, but I'm not persuaded by it, given the fact that we've got a range of other regulators that cover other professional groups. On my basis, I don't see why that would be any different, why it would create any confusion for the GMC, given that it doesn't for other health regulators. Can I ask if the cabinet secretary considered making the health and care professionals council, the HSPC regulator for PEAs and AAs, if there was any consideration given to that and why you decided that the regulation of the GMC as other parts of the UK would be more appropriate? There was a consultation exercise on which regulatory body would be most appropriate for the regulation of them. A very significant majority of those who responded to the consultation said that it was the GMC that would be the most appropriate body to carry out that regulatory function. The order that is reflective of the feedback rate, which is under 60 per cent, if I recall correctly, believed that it should be the GMC that should be responsible for the regulation in this area. The order and approach that has been taken by both the Scottish and UK Governments is reflective of the feedback that we receive from that consultation exercise. I do agree with the expansion of the multidisciplinary team. We need to ensure that we have appropriate staff, but I am concerned about physicians, associates and anaesthetic associates. A number of concerns. My first is about confusion. Why has the name changed from Physician's Assistant in 2003 to Physician's Associates in 2014? Why are we sticking with Physician's Associates? I might be asked, Nigel, in terms of the history back in 2003, why there was a change in the name at that particular point. It is important to note that Physician's Associate as a role arrived from America around about 20 years ago. They have been established for quite some time, notably in NHS Grampian in partnership with Aberdeen University's course. These courses have been running for that duration, so we have a cohort of practitioners in place already who have attained accredited qualifications using that title, and there are currently courses running using that title, so there would be significant problems in retrospectively changing it, and we believe that that would result in unacceptable delays to the further legislation to bring them into statutory regulation, which is absolutely necessary for patient safety. They are not regulated currently, so if you are creating legislation you can put any name you want. We could, but not with this legislation. This legislation would have to fall in this Parliament and in the UK Parliament, and the whole process would have to start again, wherein it looks like we are going to be in the UK election year, so we would have no guarantee when we would actually be able to bring these roles into statutory regulation. One of the things that the BMA is telling us is that patients and their families are unaware in a lot of times whether they have been assessed by a doctor or not, so following on from the question from the convener, seeing as the GMT regulate doctors, getting them to regulate somebody else, wouldn't that then add to that confusion? I've heard this argument a few times. I don't quite follow it, so there are other professional regulatory bodies, for example, around pharmacy, etc., that cover other groups that are supplementary to pharmacy as well. I don't follow this argument in some way that by the GMT taking on the role of regulating PAs and AAs in some ways will cause public confusion around the role of the GMC. If you've got a complaint to make about a PA or an A or a doctor and the regulator is the GMC that's responsible for doing that, you'll take the complaint to them. I don't follow this argument that for some reason the GMC, for some peculiar reason, it will become really confusing if they regulate two other groups other than just doctors, given that other regulatory bodies do that. It doesn't appear to cause any difficulty for the public in pursuing a complaint or pursuing an issue with the relevant regulatory body. Can we talk about money? The cost of regulating a PA will be half of that of the cost of regulating a doctor, and the Government is putting money into subsidise this regulation process. Is that fair? I think the process here is initially to get the eventual self-funding model which will operate, but this is a measure which will be for the initial couple of years in order to get the regulatory process up and running. As that workforce expands then it will be a self-funding model in the way in which most of the regulators now operate anyway. This is part of the initial process to support the GMC in taking on this regulatory role. In the cost of half of what it would cost to regulate a doctor? I don't know what the exact costs are associated with that for individuals. It's the UK Government of taking the decision that they'll fund the GMC to support the GMC in the introduction of regulation around it and in the regulation of PAs and AAs, but eventually it will move to the normal self-funding model that all the regulators more or less operate to, if not the majority of them. If you're going to regulate it, you need to have very tight definitions of what it is the profession is doing. There's very tight definitions about nursing, about expanded roles, about what a doctor does. With the scope of practice of an AA and a PA, 69% of respondents for a BMA survey said they were concerned that there had indeed been this expansion in the role to where it really shouldn't be. An example would be, I've heard, of the Medredg bleep, which is one of the most senior positions in a hospital, being held by a physician's associate. What is the scope of practice for a PA when it comes to that complaints procedure and that regulation? They're unregulated at the present moment, and the way in which we deal with them in Scotland where we have a very small cohort of around 150 operating within the NHS is that we issued direction back in 2016 around the type of role, the scope of a role within NHS Scotland, so that's already defined clearly as the GMC take on the regulatory function. They'll be responsible for setting out these definitions and the terms of those definitions as well going forward. Now, GMC have said that is not their role, and in the work that you've put out, you haven't defined what supervision means. So, in terms of how we then use them within NHS Scotland, will be determined by us, and that will be the approach that we'll take through the group that I've said to, that we'll set up, that will consider their role going forward. We've taken a very different approach, which is part of the concerns that the BMA have flagged from the UK government in this matter, where the use of PAs and As are a key part of their workforce plan going forward, and the proposed fairly rapid expansion of their use has raised a lot of concerns, and I understand that, which is why we've taken a different approach here in Scotland, and I've read outline to the BMAs that we're going to take much more of an incremental, and it will very much be an evidence-based approach as to how PAs and As will be used within NHS Scotland, and how they will be deployed within the NHS Scotland workforce, and how they'll be utilised, and that's exactly part of the process that we put in place in order to manage that. So, we're not intending to replicate the very rapid expanded use that the UK government are applying within NHS England. We are taking a much more evidence-based and a much more limited approach to how they'll be used, and how that will be defined. Can't just be clear that you said that you would have a, are you doing work into that? Is that a programme you're setting up? Yeah, I mentioned it in my opening comments. So, would you call, we've set up, set up the maps implementation programme group, which is a programme board, and that's got key partners on it. So, from within NHS Scotland, Royal Colleges are involved in that in order to make sure that we've got a very clear implementation process for the use of PAs and As as you go forward as a regulated body, and how they will be deployed and used within NHS Scotland. I've also set out very clearly to the BMA the difference in the approach that we are taking with the UK government, because I think a lot of the concerns that the UK government or sort of the BMA have around it is the way in which the UK government have taken issue of regulation around PAs and As, and also how they've set out within their workforce plan, which has conflated two issues, and the approach we're taking here in Scotland is a different one. It'll be much more evidence-based, it'll be much more managed, and it will also be very clearly defined in the role and the way in which they will be used within NHS Scotland. I totally agree in terms of regulation. It's really, really important. I should declare that I was on the Healthcare Professions Council about 15 years ago, and they have a very diverse group of professionals, and they're quite used to this sort of advanced role. I'm just interested to know, was there a debate about whether they sat neatly on the GMC or the HCPC, because they are obviously very skilled in that sort of diverse role with these advanced practices as well? Yeah, just coming back to the answer I gave earlier on, there was a debate around it, and it was part of the consultation that was carried out, where we asked for feedback on which body would be the most appropriate to regulate PAs and As, and the very clear majority, just under 60%, said it should be the GMC. It should be responsible for doing that. The GMC have also been very clear, and they believe that they're capable of actually carrying out that regulatory function as well, and I've already been putting in place arrangements to manage that process. I think they gave evidence to the committee, and we've met with them and discussed that matter with them as well. I used to be regulated by the Healthcare Professions Council, and it regulates a whole range of bodies, different professional groups or idea, and I don't think that it causes any confusion for the public. So I think the idea of an R-regulator taking on a bit of additional regulatory work causes great difficulty for the public to be able to understand. It's not that I disagree, it was just of interest to know with that diverse group already being, as a whole regulatory body, and if it made sense for them to go there, I suppose was my question. Thanks, convener. I'm going to declare an interest as well as a registered nurse, and I worked with physician assistants and now physician associates when I worked in a level 1 trauma centre in California, including anesthesia as well. I've been interested in following this, and I've looked a little bit at the American perspective, where in May 2021 the House of Delegates passed the resolution to formally name physicians associates as associates, and I know there are issues where there's concerns where during the training of physicians associates or anesthesia associates that it might impede the ability of junior doctors to find time for their training as well. Has that something that's being considered so that we can allay concerns that might impact the training of our junior doctors? I think that that's a very legitimate concern to be raised, which is why, as I mentioned to Dr Gohani, the measured approach that we are taking and the evidence-based approach we are taking to the use of PAs and AAs going forward as well, and where they will sit within NHS Scotland and our workforce development going forward, Scotland can see a wee bit more about that, because it is important that we make sure that the important training environment for our junior doctors is not compromised as a result of this, but I believe that that can all be managed if we do that in a proper, programmed way, with a very clear sense of where we see the role of PAs and AAs and where they can help to add value to our healthcare system. Ultimately, investing in the PAs and AAs workforce should help us to create additional clinical capacity across the system and so liberate the time on the part of doctors that can then be invested in other activities, including supporting high-quality training opportunities for doctors in training. Clearly, we need to make sure that we are carefully planning any plans for future growth of PAs and AAs roles in order to ensure that there's sufficient educational supervision capacity across the system in order to support those individuals alongside doctors and training, and certainly that will be part of the discussion that takes place through the Maps Implementation Program Board that the Cabinet Secretary referred to a short while ago. We will be sure to ensure that any future plans around growth take account of the training needs of those doctors and training in the system as well. Just another wee quick question, it's about the scope of practice of anaesthesia associates, for instance. In my experience as an operating room nurse, the anaesthesia associates would anaesthetise patients that were pretty young, fit, healthy, they weren't, they didn't have additional comorbidities, they didn't have out-of-control type 1 diabetes, for instance. It was very structured in the scope of what they were allowed to anaesthetise patients, for instance. It was monitored anaesthesia care, it was quite limited, and they would support consultant anaesthetists in other sicker patients, for instance. In looking at this taken forward regulation after having 20 or 30 years of non-regulated workforce, this is about safety and about making sure that everybody understands the parameters of the scope of practice. The Royal College of Physicians website says that there are over 40 specialties across primary, secondary and community care, and they say the role of the physician associate is varied, dynamic and versatile, and that they are medically trained generalists and their health professionals. Can I just ask you to reiterate that this is about optimising the safety of patients wherever they are being looked after, whether it is in primary care or secondary care, and in the community? Absolutely. Given the role that some of them play at the present moment in the need for us to have a statutory regulatory process in place, so that is why I said in my opening statement that the heart of this is patient safety. So it is about accountability. For healthcare professionals in the role that they carry out, in the very important role that PAs and AAs play, and you mentioned, for example, around anaesthesia assistants in the role that they can play within the theatre environment, it is important that they are also accountable for how they manage that provision. Of course, to carry out these things under medical supervision is well, but it is important that there are very clear lines of accountability and responsibility that go with that. So that is all the more reasons to why we need to get into a regulatory environment where we have statutory regulation of these groups, which I think is in most patients' interests, and I think it is also in a way that our healthcare systems interests that they are properly regulated, the role being clearly defined and also very clear accountability for any decisions or actions that they take that they should be held to account for in a way that other healthcare professionals are. Okay, thank you. Paul Sweeney. Thank you, convener. I would just like to pick up on points raised by the Association of Aneutatists in response to our call for views on this matter. They highlight the issue of distinction of registration. So whilst they welcome the different registration number that A's and P's will have to distinguish them from doctors under GMC registration numbers, they have called for a separate register that is distinct from doctors, whether that be online or in print form. This is order to provide absolute clarity for patients and others accessing the registers. It is to protect everyone from accidental or deliberate misrepresentation. There is no legitimate reason that this could not be done with modern information technology systems. Would the cabinet secretary be sympathetic with that perspective? Yeah, I understand or consider the last nige, maybe to say a bit more in terms of just the practical application of the process and how the GMC might address some of these issues. Yes, in terms of the sort of modern IT infrastructure that you've mentioned, it's important to note that all this data will be held on a database by the GMC. It will be in reality in one database, it will be searchable according to the individual professions and the individual professions will have a slightly different alpha numeric format or basis for their actual registration number. So in reality it will appear to all intents and purposes to be separate registers? Okay, so if I were say searching for an individual, I would have, I could only search one doctor's register and then I would have a separate web page to go into the search for physicians associates and anesthetists associates. You would be able to filter, but this is work in progress and that's a matter for the GMC as part of their broader programme and how they actually bring these groups into regulation once the legislation is in place because they can't begin that process properly. Their council can't take those decisions until they have the actual powers to do so. Do you as an organisation have a role in discussing the specification of such matters with the GMC or is that a matter entirely for the GMC? It's a matter for the GMC's council to make the final decisions, but we do work closely with the GMC's office in Edinburgh and also their headquarters in London. It's worth adding that this now brings the GMC into the competence of the Scottish Parliament, which ultimately obviously could be accountable to the Parliament and to this committee. If it believes it's not taking an approach, which it believes is consistent with whom they think is the right way to do things. So it provides the committee with a direct route into the GMC in a way that hasn't been there previously. That's certainly an interesting point that you've raised, cabinet secretary. You just also wanted to quickly raise the point of scope of practice also raised as a concern by the association of anaesthetists. They highlight that there should be a national scope of practice for AAs both on their qualification and for any post-graduate extension of practice and that any future changes to scope should be developed in conjunction with the regulator and should be agreed at a national level and that it shouldn't be, for example, individual health boards to determine that. Would you agree that that's an appropriate way forward? Do you have anything to say on that matter? So it's part of the work that we're looking for the national board to take forward, Scott Wood, to say a bit more about that, but I think there is a need for us to make sure there's a consistent approach introduced. Absolutely, so scope of practice in relation to PAs and AAs, it will be individual, specific to the individual healthcare professional in question, so it will take account of the skills and knowledge that they've attained in the course of their initial training. It will reflect any constraints or limitations associated with the role in which they're deployed at a given point in time and finally it will reflect the skills and experience that they've attained over the course of their careers in the form of continuing professional development. So in the case of PAs, where we've heard, of course, that they can be deployed in a wide range of healthcare settings, it's hard to draw firm lines in terms of scope of practice. You need to create some flexibility. That said, we are very happy to look at what further guidance might be required exactly as the cabinet secretary described earlier on in his comments in order to support organisations, supervisors and PAs and AAs themselves to define that scope of practice. Now, we already have guidance published by the Association of Anesthesia Associates around scope of practice to support those discussions at the moment and we understand that the faculty of physician associates are currently considering producing similar guidance, so we'll keep a close eye on the development of that guidance, keep it under review and then we will consider what further action we need to take to supplement that in order to deliver the ones for Scotland approach to the deployment of the roles that we want to see for NHS Scotland. I appreciate your comments. Thank you. I thank the cabinet secretary and his officials for answering the committee's questions. We now move to agenda item four, which is the formal debate on the affirmative instrument on which we've just taken evidence. Cabinet secretary, can I now ask you to speak to and move motion S6M-11668? I've nothing further to add, convener, but I'm happy to move the motion. Thank you. Can I remind the committee that members should not put questions to the cabinet secretary during the formal debate and officials may not speak in the debate and invite members who wish to contribute to make themselves known? I'm not sure if I need to declare my register of interests again, but I shall do as a practicing NHS GP. I have met with association of anaesthetics, BMAs, Scottish GMC on multiple occasions about physicians associates and anaesthetic associates. I have a number of concerns about the role and that's really important when it comes to regulation because you can't regulate someone or a body if you don't know what their role and scope of practice is. So supervision level has not been defined. Is it one-to-one? Is it two-to-one? Is it three-to-one? You know, and these numbers go on. Emma Harper in her questioning spoke of the tightly defined role of an anaesthetic associate in the US, but let's look at the two issues that we have here. The first is those fit and healthy patients that Emma Harper spoke about are actually exactly the type of patients our junior doctors require to train because when you start off, you cannot start off on the really complicated patients. You need to start off on patients who are fit and healthy and people that you can anaesthetise obviously with supervision, but that's really important. So it does impede training and potentially even more. Also here I have heard of, let me make these points and then yes I will. So here I've also heard of anaesthetic associates anaesthetising children. I'm also concerned about how anaesthetic consultants know how to supervise and what their level of, when something goes wrong, what their level of cover is when this happens, and they have never been trained on how to supervise anaesthetic associates. I'm just interested. Sandesh Scott-Hunney, you appear to be making an argument against physicians assistants and when we've heard that they've been practicing for 20 years and that this instrument is about regulation of those professionals, can I just be clear? Are you making an argument against us having those professionals in the system? No. What I'm arguing is yes this is about the role of regulation. Of course regulation is important, it must occur, but you cannot regulate what you cannot define. So scope of practice is a very important part of that regulation and as is supervision level. Scope of practice, we know that there has been an expansion in what it is. Our PAs and AAs have been asked to do and turning to PAs, I know of GP practices almost entirely running on allied health professionals, thus saving the practice money, but providing potentially a two-tier system and service to patients in remote and rural areas where they're not going to be seeing doctors in the main, they're going to be seen by others and with that expansion of that PA role. Also Is Sandesh Gohani arguing against multidisciplinary teams and not acknowledging the advanced practice that there is in specialties within nurses and EHPs to provide better and more appropriate care at times to patients in those practices? The work that I do with my MDT is absolutely vital. Our pharmacist, our nurses, in fact, I can tell you that my practice nurse at handle's diabetes is better than I do because that is a lot of what she does, but my argument is you're seeing an expansion in the roles of a PA, which means that they are no longer looking to get doctors into that practice, they are expanding into the PA, thus creating this dichotomy. The last thing I'd like to say is I've also heard of reports of PAs setting up privately, saying that they can offer all the same services. If we can't define the supervision level and we can't define the scope of practice, it's very difficult to be able to regulate and these things have to be very tight and have to be defined in the same way that Emma Harper spoke about when we were talking about what happens in the US. In my experience, in the US, it's very regulated. When I describe the fit and healthy patient, the American Society of Anesthesiologists have an ASA classification for fitness of patients to undergo anesthesia, so it's a classification one through four. That's already in use in this country. It's a long time since I worked in the operating theatre for seven years, but we use this classification for junior doctors to be able to assess patients so that they can have a registrar doing anesthesia, surgery or consultant, for instance, and then it allows an assessment of a patient through safety and everything like that. The scope of practice that they do, they're already working within the scope of practice. Again, there's lots of different specialties that, if we're talking about physicians, associates in the community or in GP practice or whatever, what we need to be careful about is that this is about regulation where there has been an absence of regulation so that we can promote safety and for patients no matter where they're working. I've worked in areas of departments where care can be led by a team with lots of different people with different scope of job and everybody knows their role and it works absolutely fine and ultimately in a team environment, the physician, the surgeon who's a consultant would have the buck stops here type of ability to direct the care so I am interested in the whole issue around supporting our PAs and AAs in order to practice and develop their scope and I don't think we're suggesting that the PAs and AAs are going to be calling themselves doctors. Thank you, Ms Harper. If that's all the contributions from members, cabinet secretary, would you like to sum up and respond to the debate? Thank you, convener, and I've listened very closely to the issues that have been raised by members of the committee on this matter. I think ultimately we should keep in mind this is about helping to promote patient safety. So, for example, the use of PAs, for example, even PAs sitting themselves up in private practice are unregulated as it stands at the present moment. My view is that they should be regulated and we need to be clear about the terms of that regulation as well. I think it's also worth keeping in mind is that most health regulators don't operate on the basis of setting out scope of practice. What they do is that they supervise or they deal with issues on the basis of whether you were within the scope of your competence in the role that you actually had, because people progress to their careers and get greater experience and understanding, and as a result they should be operating within the scope of their competence at that particular point, and that happens right across healthcare professionals in how the regulatory process operates. Additionally, aspects such as supervision are dependent again on someone's scope of experience. And the skills which they have, someone who may move into a new area where they have got less experience and less knowledge, may be put on an increased level of supervision in order to achieve that experience and that knowledge. Therefore, the issue of, I think, this issue of scope of practice is something which the regulators already deal with in terms of, they deal with issues whether you go out with the scope of your competence and your practice ability, and supervision is a very dynamic provision, is very much dependent again on the environment and someone's skills and their needs at that particular point. I know when I qualified my level of supervision was greater than it was as I moved through my career reflective of the experience and knowledge which you build up in my regulatory body would expect that to happen in terms of my competence. And I also think the issue of the, for example, the use of things like PAs etc within general practice right now, for general practice, they're out with the scope of even the letter, the direction that we've set as a Scottish Government because they can be directly employed by a GP practice to be deployed in a way that they see is most appropriate for their needs. We are not able to give any direction around that in a way in which we can within NHS as it stands, again, why they should be regulated. So, I think that the key thing here is that there is a process being taken forward by the GMC in order to ensure that both PAs and AAs are appropriately regulated, and I don't think that it is in the interests of patient safety for these professional groups who are ready with us and operating within our healthcare system to mean unregulated. In my view, it will enhance patient safety and accountability by introducing this regulation, which is why it's critical that this order is passed today by the committee. Thank you, Cabinet Secretary. The question is that motion S6M-11668 be agreed to. Are we all agreed? Yes. No, we are not all agreed. I will call a division by inviting members to indicate in sequence by show of hands those for the motion, those against the motion and any abstentions. So, the result of the vote is for the motion 8, against the motion 2 and there were no abstentions. Thank you, and that concludes consideration of the instrument. At our next meeting, we will be taking evidence on the draft Funeral Director Code of Practice 2024 from the Minister for Public Health and Women's Health, and that concludes the public part of our meeting today.