 silver is coming back we. Good morning and welcome to the first meeting of the health social care or support committee in 2023. I've not received any apologies for today's meeting. We're all here and the first item on our agenda is to decide whether to take item three in target and wherever our members agreed. Thank you. The next item on our agenda is an online evidence session on the Scottish budget for 2023-24. We'll be taking the evidence from the I welcome and happy new year to the cabinet secretary, Humza Yousaf, who is joined by Richard McCallum, the director of health, finance and governance from the Scottish Government. Cabinet secretary, we obviously want to talk about the budget, but it would be remiss of me not to mention the announcement yesterday of additional funding that is getting made available to NHS boards around the country to deal with the situation that we have seen over the last couple of weeks. I would like to ask for some clarity around the extra funding that has been given. If you can maybe just take me through that first of all, what extra funding has been given and how is it going to be deployed? I mean, can we know that you were going to ask about that specifically? I mean, I think it is probably best for me to lay that out to the chamber in the statement later on today, but there will be two essential areas of focus in the First Minister. Outline needs a very broad term so that I can give the detail to Parliament, as we said throughout yesterday. I appreciate that. I do not want you to pre-em… Yes, I encourage that. …of the statement. Of the playing officer. There are two areas of focus. One is freeing up more capacity for interim beds. We have used interim beds already, but there will be slightly different features to what I announced in a few hours' time in the chamber, given the pressures that social care is facing. The second will be to try to bolster the workforce around NHS 24, in particular, who has been exceptionally effective in relation to keeping people away from busy, acute sites. The vast majority of those who call NHS 24 and get through to a call handler get the appropriate triage without having onward transfer, but I will lay out both the funding, the pounds and the pennies, involved in the statement this afternoon as appropriate. I did not mean to put you in that position of asking for the figures, and I know that you cannot really give that until you give the statement, but it is helpful just to mention that. It would be strange if we had not mentioned that additional funding is coming forth for the winter pressures. On to the emergency budget review. Some tough decisions had to be made to fund the pay offer that has been made to NHS staff. I believe that it is an average of 7.5 per cent, which is a great deal higher than any other offer in the UK. The question has to be asked. There are a number of things where you have had to take funding from certain other areas in order to fund this. I want to know how those decisions were made and maybe you can take me through. The question is, how are we, as a Scottish Government, able to make this increased offer to Scottish NHS staff in a way that has not been made by the rest of the UK? How can we afford that, essentially? I should have started my other remarks by saying happy new year to you and to the rest of the committee. I hope that everybody genuinely has a bit of downtime and a bit of a break. I suspect that, as we get into this session, I might feel like a distant memory. I thank you for the question. It is first and foremost important for me to say that the £400 million of savings around the EBR—you are absolutely right—was, of course, in part to do with the record pay offer that we have given to NHS workers, but it is also to do with, quite significantly, the impact of inflation through particularly the impact of the UK Government's many-budget and the inflationary pressure that has brought to our budget. Just by way of the health and social care portfolio, Richard will correct me if I am wrong, but the impact of inflation alone is about our budget that is worth £650 million less compared to when it was set in December of the previous year. We are having to both try to find money to give a record pay offer to VRT as best as we possibly can industrial action, and that threat has not been completely negated, as you know, and to also deal with the impact of inflation. We obviously gave detail of the £400 million and where that money is coming from—some Covid savings, somewhere in social care, primary care, mental health and so on and so forth—and we gave detail of that. It would be completely false of me to sit here and say to you that that has not had some impact on service delivery. You cannot take £400 million at a budget and not expect there to be some delivery impact. Many stakeholders of BMA have been very vocal about some of those savings in relation to primary care, stroke association, and some of those savings in relation to the thrombectomy services, for example. Stakeholders have spoken about those deliverability challenges. I suppose that to answer the last part of your question, I obviously cannot speak for the Welsh or UK Governments in particular in Northern Ireland in a slightly different situation. Essentially, it is about making difficult choices. That is how we afforded the pay-offer that we have put on the table. Thus far, it means that Scotland has been the only country that has not seen nurses and ambulance drivers walk out and strike in the midst of an exceptionally difficult winter—not just an exceptionally difficult winter here but one that is taking place right across the UK. Strike action is not completely negated. There has been no three trade unions—the RCN, RCM and GNB—that are still in dispute around the pay-offer. We will continue meaningful dialogue with them. EBR is an exceptionally difficult process to go through but one that I thought is necessary to try to have strike action and get, frankly, a fair pay deal for NHS workers who absolutely deserve it. I note that, in Wales, the Welsh Government has said that they want to be able to match what the Scottish Government has done but they just cannot. I want to ask—you have had to make these difficult decisions—you have had to reprofile money from the health budget and deal with inflationary pressures on the health budget. Has any additional funding been given to the Scottish Government from the UK Government to deal with any of that? No, the answer is short. We are obviously keeping a close eye on what has been—any time there is a discussion about quote-unquote new money so you may have seen that there was an announcement yesterday by the UK Government about what it is planning to do around delayed discharge and a lot of focus was on additional bed capacity, much as it will be in Wales and Scotland and Northern Ireland. It was touted as new money but we asked HMT Treasury and they were told that it is being found within the department. There are no consequentials to that so every time there is an announcement we are obviously keeping a really close eye to see if there are any further consequentials but I have to say that I am not holding out any hope that there will be any additional money coming in this financial year but I am also mindful that there is some level of discussion that is now taking place at a UK level between trade unions and the UK Government. If there is anything that comes in year then of course we have a commitment to pass health and social care consequentials to the health and social care portfolio. Okay thank you, thank you for your honesty there. Can I hand over to Sandesh Gulhane? Thank you convener, cabinet secretary. Hello. Just yesterday the First Minister said there was a slight reduction in delayed discharges and yet today we've seen the worst levels of delayed discharges ever with the average number of beds occupied per day due to delayed discharge sitting at 1,950. With the First Minister announcing block bookings of care home beds I have two questions. The first is over what timescale will this begin and the second is what level of change do you expect to happen to the delayed discharges? The question is a fair one, the level of delayed discharges is far too high. It should be said that the First Minister was talking about real-time data, the data that you are referring to in terms of the monthly data has obviously got a time lag to it but your right levels of delayed discharge, I'm certainly not going to argue, are far higher than we'd like them to be per issue in Scotland and right across the United Kingdom. So I'll give further detail of this in the statement. I'm very conscious of not preempting too much of what I said in the statement. The focus will be on interim beds and the reason for that. Again, I'll give the detail of how many beds we're looking at potentially with the funding again which I'll give detail of in the statement later today. Those interim beds can be used for a number in number of different ways. They can be used for those who are waiting for a care home placement, so we'll put them in an interim placement. I think that we frankly should also be looking to use those interim beds for those who have not quite had their assessment yet, so we can assess them when they're in the interim bed space because whatever clinician I talk to, doctor or nurse, whoever in any busy acute site and I'm certain that the whole committee knows this, they will continue to tell us that the exit block is the number one issue. It's not the only issue, but it is the number one issue, so creating that capacity is going to be important. Over what timescale? Again, I'll give some detail of that, but I don't think I'd be sharing too much detail from the statement if I say that that work has already started. You know that I brought forward a ministerial advisory group that brings COSLA, Scottish Care, chief officer, SOLIS and so on around the table. That is one of the key issues that we have been looking at. Again, without pre-empting the statement, one of the reasons why we have about 600 interim beds that we already use, the very clear message from Scottish Care coming through is that the rates at the moment that you are paying for the national care home contract rate doesn't take account of, for example, the inflationary pressures, the high energy costs when the contract was first set. Again, without pre-empting the detail of the statement, we think that we found a way around that, at least in the interim short period of time. Again, today we saw the worst ever 8-12 hour wait-in A&E with only 56 per cent seen within four hours, and, obviously, hundreds of thousands of patients are waiting for treatment. Do you feel that the changes announced yesterday will significantly improve those figures, and will you be announcing further measures in your statement? That is a fair question. We expect from the action that we are taking to see some immediate improvement. Your question was significant. Do you see significant improvement? There is not a silver bullet. There is not a panacea. Dr Glannie knows us, given his clinical experience, but I think that it will see an improvement. As well as the shorter term measures that I will be announcing in the statement today, it is really important that we, as a Government, do not lose focus of the medium to longer term issues, particularly in our own social care. The national care service is a part of that, but let us all accept that we have to make improvements now, as opposed to waiting for a national care service to become operational. As well as the shorter term impact, the immediate improvement that I expect to see as a result of the action that we are taking on the 8-hour waits, the 12-hour waits, and, interestingly, that is where we will see the improvement first. We will see the improvement, as you know, given the flow through a hospital. We will see the improvement at a 12-hour or 8-hour waits before we see them probably in the four-hour waiting time target, necessarily. We will not lose focus of the longer term changes and reforms that we have to make to social care, which will help to make a long-standing, more sustainable impact in the longer term. Although we are focusing a lot on the back door delay discharge and understandably so, because it is the issue that is raised most predominantly by clinicians and healthcare leaders, we also will not lose focus of the front door. I will talk about that in the statement too, in terms of how we continue to drive down demand at the front door in terms of the preventative agenda. There is a large increase in the budget for NHS 24. Can you explain the thinking behind that and what impact it is going to have? Yes, thanks for the question. There is no doubt that NHS 24 is absolutely vital service, critical to us. It has been an extremely successful service since its inception and creation, and it is very clear from the data. NHS 24 has exceptional levels of data, as you can imagine, call data, call waiting data, how many are triaged, how many people are transferred, or recommended to transfer to A&E, for example. It is very clear from the data that the vast overwhelming majority do not need to transfer to A&E. NHS 24 is critical in trying to reduce that demand to the front door. The more we can bolster staffing levels in terms of call handlers and clinical staff, and we have increased the clinical staff quite significantly, if I look at figures from September to September 21 to September 22, a real increase in those clinical nursing staff, that have helped with that. The other area and the reason why you will see funding as it is for NHS 24 is that there is definitely more that we can do in the digital offer. NHS 24 has an app launched that you can download, whether you are on Google or Apple. NHS 24 has self-help guides, but it has a great service where you can see the pharmacy, GP services and other primary care services that are local to you, what their opening times are, et cetera. It is a minimum viable product at the moment, so it is just launched. It is going to grow arms and legs as time goes on, and some of the funding in the budget will help us to do that. In short, staffing and digital is where a lot of the focus will be for us. Can the cabinet secretary provide clarity on how much of the budget relates to the development of the national care service? Yes. It is a good question and one that we anticipated coming up, because members of Parliament are right to ask for that clarity on the national care service. If you look at our current financial memorandum for the NCS, we talked about this coming financial year, being in around the £63 million to £95 million mark. You will also probably be aware that the Finance Committee has come back to the Government to say that it wants to revise financial memorandum, and there has been a fair degree of scrutiny. What I propose to do is once we have that draft of the revised financial memorandum that we are working on, we will go back next month to the committee with the revised financial memorandum. That will lay out in detail. Much will be spending specifically on the national care service, so it is work under way, given that we have been asked to provide a revised financial memorandum. Thank you, convener, and good morning to the cabinet secretary and a happy new year. I wonder if I can just pick up on that point about NHS 24 recruitment. I appreciate the way further detail is after the cabinet secretary's statement, but he will recall that last year he and I had an exchange regarding contact tracing staff and the potential for them to be redeployed into NHS 24 to bolster capacity. At that time, the cabinet secretary had given an undershaking to try and do as much of that as possible. I do not know if he can say just now how many of those staff were transferred, or if he can write to me with further detail on what the transfer was. I can certainly write to you. Forgive me, I do not have just checking, but I do not think that I have quite that level of detail. It was not just NHS 24, of course. It was redeployment into NHS boards territorial as well as non-territorial. Forgive me, I do not have that detail to hand, but I am more than happy to write to the convener who can share it with the rest of the committee. I will move on to questions from Tess White. Tess, joining us remotely. Hello, thank you, cabinet secretary. I acknowledge that you do not want to provide budget allocation for NHS 24 until this statement, although I am disappointed to hear that. However, I raised NHS 24 capacity with you in October, and at the time you emphasised the additional recruitment that will take place to support this crucial service. Can you at least indicate this morning, cabinet secretary, how many new NHS 24 staff have been put in place since you made that pledge in October? And how many you intend to recruit over the coming weeks? I am not sure that the nature of Tess White's disappointment, so she should come back to me if she wishes in that regard. The budget for NHS 24 for 2324 is outlined in the budget document in terms of any additionality, as I say. I think that it is right and appropriate that we have agreed to update the entire Parliament in the chamber, so we will do that. In terms of October to December, again, if Tess White does not mind, I will come back to her with the exact figures. There has been additional recruitment, because I have seen a note from NHS 24 in that regard since October. I will come back to Tess White with the exact figure, so I do not give her the inadvertent figure by mistake. That is my question, convener. Thank you very much, convener. I am keen to start with the sustainability of management of finances in NHS boards. Audit Scotland has previously highlighted a lack of stable senior leadership with high turnover and short-term tenure. Indeed, when we went through this session last year, we were discussing some similar issues. It would be good to know what progress the cabinet secretary feels has been made in terms of financial stewardship within boards and whether or not he feels it has to be more done to tackle those issues. It is still a very uncertain time, although we are, I think, through a different phase of dealing with this pandemic and much more into the endemic phase. It is still a very challenging time, as we all know, for NHS boards up and down the country. We are trying to revert back to some of the pre-pandemic processes that we had in place. For example, we are obviously urging boards this financial year to get into a position of balance. It is fair to say that we do not expect every single board to quite get there, but we are making it clear that, if there is further brokerage required, as per pre-pandemic arrangements, they would have to look at repayment of any additional brokerage. We are getting back into practices that we had pre-pandemic, which help the financial stewardship of NHS boards. There are still a number of boards, as you know, that are escalated. Three boards are escalated in relation to the financial performance, and we continue to work exceptionally closely with them. Given the phase that we are in in terms of the pandemic, we are taking an even more closer look at what can be done to try to get them to de-escalate in terms of their financial performance in that respect. I still think that there is a way to go in this regard, if I am being frank and honest, because, given the experience of the past two and a half years, almost three years of the pandemic, the financial landscape has been so uncertain and unstable, given that we have had to suddenly fund a whole new vaccination programme and so on and so forth, that I am very keen that we are now in this new phase that we are getting back to really sound financial management. I certainly get that impression from my annual reviews and mid-term reviews that I have with boards. So, would the Cabinet Secretary be confident that, when we come back around this table to discuss these issues six months a year down the line, there will be significant progress made particularly in those three boards? Does he expect them to have returned to a position of those usual financial controls, if you like? In short, yes, I would expect significant improvement when we are sat back around here in a year's time, particularly in those boards, yet absolutely in those boards that are escalated, the three Ayrshire and Arran borders in Highland that are escalated in that respect, I would expect there to be significant improvement. So, we have already been in discussions with those boards around the escalation, as you can imagine. We have a process escalation in tails, as the member knows, a higher level of monitoring, supervision and support. That is all on-going, but fair to say, yes, I would be very disappointed if we were sitting here in a year's time and there hasn't been that significant improvement, particularly in those three boards. I wonder if I might ask about something else that Audit Scotland has consistently raised, and that is the impact that multi-year budgeting would have. I suppose that the adverse impact that a lack of multi-year budgeting has in terms of longer-term financial planning and ensuring that innovation can be planned for and all those sorts of things that we are keen to see. Can I ask the cabinet secretary what is his view on how multi-year budgets might assist in achieving financial stability and, indeed, what would he perceive as the barriers to being able to offer those multi-year settlements? I might bring Richard in, given his experience in this regard shortly, but what I would say is that I do not argue with the premise from Audit Scotland, or indeed, I think that deputy conveners are making here that multi-year budgets clearly help with planning. It is not just unique to the health service right across portfolios, and that is why the spending review is an attempt to give at least a high level overview of what budgets might be for future years. Our difficulty is clearly just the unstable economic circumstance that we find ourselves in. We have been talking about sitting here a year from now. Let's go back a year, and I do not think that any of us would have seen inflation at the levels that we currently see it at, nor, indeed, some of the geopolitical factors playing out and having an impact on the economy here in the UK and, indeed, in Scotland in the way that they have as well. There is so much that we can do around, for example, multi-year spending reviews. As we have done, they are not budgets, and I accept that point. They do not go into the level of detail that a budget necessarily would, but that is an attempt at a high level to give some degree of what the financial envelope will be for future years. I accept the point entirely that that is different to a budget and multi-year budgets. It could be more helpful, but I think that the barriers that you asked me the question is just the instability in economic circumstances, both domestically and globally, too. I do not know Richard from your experience if there is anything to add. Just two things I would add. First, I think that Capsaic makes a point about the resource spending review, and I think that that has been massively helpful. That being published last May gave at least an envelope and a window of what we expect to be budgets over the next few years. Obviously, that is subject to the annual budget process, but that has given a kind of planning framework, which is really useful for us as a portfolio and also useful for our discussions then with the health boards in terms of what they can expect for the next few years. I think that the second point that I would just make is, as the cabinet secretary mentioned, not just with the escalated boards, but with all health boards, we are engaging with them regularly. I have regular meetings with the directors of finance, and as you would expect, we work with them on a range of planning assumptions, whether that is in relation to pay, non-pay and many other factors. Just by way of example, health boards are coming forward with plans before the start of this financial year in terms of what their plans are, not just for 23-24 but for the next three years. There is a context that we work in with health boards that gives us that longer-term planning environment as well. Fandesh, you had a question on financial sustainability as well. I am sure that you are aware that around 85% of all patient contact is in primary care, and during the Christmas break, I worked as an NHS GP around different parts of the country, and they are all struggling with demand, and allied healthcare professionals are vital to help cope. With a £65 million cut to primary care budgets, these additional value staff are at risk. Do you think that the GP will be financially stable going forwards? I think about the reference comments from the BMA in relation to the EBR savings that we looked to make. Obviously, we have a significant budget for 23-24, but I do not doubt that the impact of the reprofen that we had to make in primary care had an impact. I am not going to argue with that, neither with Dr Colhaney or, indeed, with the BMA, but it is why our strategy over a number of years has been to increase those multidisciplinary team members that he talks about. We have recruited over 3,220 since making that announcement on top of that, increases in general practitioners, too. I still think that we have a way to go in that regard, but I am pleased that we were able to ensure that primary care is well funded for the primary care budget for 23-24, and that puts on a sustainable footing. All that being said, not like I need to tell Dr Colhaney, given that he is working in primary care, the workload pressure is still exceptionally significant on our GPs, even with that multidisciplinary team in place. That is why I am keen to try to make sure that workload is spread more evenly. For example, I have spoken about NHS 24 and what more can we do around NHS 24, too, but you will see from the 23-24 budget that there is a significant investment in primary care that I am proud to stand by. Colleagues, I am aware that there are a couple of members who need to leave before 12. I am tempted to move our theme on NHS state and sustainability forward, to allow members to do that. Can I go to Gillian Mackay first of all and then to Tess White, and then I will revert back to our schedule? The increase in the cost of energy will undoubtedly be having an impact on the cost of running NHS buildings, as well as food inflation among many other rising costs. Does that raise issues for how individual boards use their estate and what impact could that have on boards to be able to deliver services? There is no doubt that it has impacts on budgets and being able to be innovative, whether it is with the estate or through other innovations, to try to mitigate the impact of that. You will know from the 23-24 budget that we have increased funding to boards by around about 6 per cent, just under 6 per cent. It is a significant increase. I should have said from the offset that the health and social care portfolio is getting an additional billion pounds. That is a demonstration of how much the Government values our national health service. That is more than the consequentials that we have received. All that being said, inflationary costs are putting real pressure on us. We have a number of capital projects that we are investing in. It is important to say that there are also significant amounts of refurb and not just normal maintenance refurbishment, which is very important. However, a number of health boards are looking at how they make their buildings more carbon-efficient towards our net zero targets and our net zero health plan. That does not come without upfront capital cost, which is something that we are very mindful of. The net zero agenda was always incredibly important. It has taken an even greater importance given that it involves an upfront cost and the eventual savings that you could see in relation to energy costs in the future. The cabinet secretary mentioned the net zero health service by 2014. The public will obviously be aware of the impacts that buildings and transport to and from hospitals will have on those ambitions, but one of my areas of interest is the environmental impact of medicines and what we are doing to tackle that. What work is on-going to engage with patients and clinicians on some of the alternatives that we might need to move to? What financial impact could that have on NHS budgets? Obviously, some of those alternatives may be more or less expensive than some of their alternatives. I referred to Gillian Mackay to our net zero strategy, which I know that she has seen, because she and I have had conversations about it in the past. That goes into a great level of detail around a few areas. We have talked about capital infrastructure, and that is right. We have to look at the estate, and particularly existing estate, as well as new estate such as the national treatment centres, the replacement munklin and so on and so forth. We have to look at how we make sure that those projects are meeting our net zero ambitions. That is going to involve probably additional costs for those particularly new bills, and we have to be upfront about that. The second point that we look at in quite a lot of detail is treatments. There is already really good innovation in this space and really good practice in this space about treatments that release less carbon into the environment. One of the areas of focus that I am quite keen on is asthma and the use of asthma inhalers, and switching to more carbon friendly treatments for asthma. Obviously, we want to focus on the preventative, and there is a lot that we can do in the preventative space around asthma. That is the first focus, but for those who have inhalers, looking to get them into more carbon efficient inhalers and carbon friendly inhalers, is what we are trying to do. I have seen that up close. I met a couple of patients in Dundee in the GP practice who were talking to me through the difference that they made to them, so they felt a lot better for that switch. Of course, it helped with the environment too. There is a group of GPs—I am trying to remember if it was to your side specific or more wider than that, but I will take a look at that and come back to you—but there certainly is a group of GPs that have got together to look at the issue of how to make treatments at a primary care level more carbon neutral where they can. From a secondary care perspective, as I said, we have outlined in our net zero strategy the treatments that we think and what we can do in our own treatments to certainly improve our carbon footprint from an NHS perspective. The total maintenance backlog bill across Scotland's 14 health boards has shockingly reached more than £1.5 billion. What budgetary provision is in place to cover this bill and why is the 2021 commitment to invest £10 billion over the next decade to replace and refurbish health infrastructure, not mentioned in the 2022 programme for government or in the 2023 to 2024 budget? I know that the figure was one that had been released publicly in terms of the maintenance backlog. We went back to the query that was made to correct it at the time that the figure was incorrect. It is closer to £1 billion still, a significant maintenance backlog, but it was overinflated by around about £500 odd million because the figure was incorrect. Nonetheless, test point stands as a significant maintenance backlog. We have committed over the capital spending review period that will invest more than £1 billion in enhancing or refurbishing existing healthcare facilities and updating and modernising medical equipment. That is essential. We will do that. It will take time. That is why it is over the course of the capital spending review period. It is a fair question. The second question is very fair from Tess White. Why is it not being mentioned? It is not because that commitment does not stand. The commitment to £10 billion over the course of the decade stands. We always thought and it has always been the assumption that that will have to be backended towards the later years, given the financial circumstances that we were always going to find ourselves in and have been exacerbated through various different factors. We are still committed to that £10 billion investment over the course of the decade, but it will undoubtedly be backended towards the later years. Now, we will look at Covid-19 recovery questions from Emma Harper. Thanks, convener. Good morning, cabinet secretary, and good morning, Richard. In our briefing papers, and I know that the convener has mentioned this already, that specific funding for Covid-19 no longer exists. We do not get any more money from the UK Government, so any funding for Covid-19 recovery has to come from the Scottish Government budget. I am interested to know, cabinet secretary, what level of funding in the 2023-24 budget the proposed budget relates specifically for the Covid-19 recovery? Emma Harper is right. There is a unilateral decision by the UK Government to withdraw funding for Covid-19. In some respects, we are always going to get that position. I think that my argument to the UK Government was always that it should be phased, as opposed to a unilateral withdrawal. We have gone from spending billions of pounds on Covid and getting additional funding for that to the tap being turned off in that regard. It should have been over the phase period, but we have had that argument and it is not one that we have won, so we are where we are in that position. In the 2023-24, to answer Emma Harper's question, we have funded about £250 million, which includes vaccinations and testing protect. The remaining costs for Covid will have to be managed within those baseline budgets as we move to a position where Covid is going to be part of our everyday lives. We are going to live with Covid undoubtedly for a number of years to come. We also wait to see what further JCVI advice there is in relation to future vaccination programmes. That is where the big, big cost comes from clearly when it comes to Covid as well. To answer your direct question, 250 million is provided within 2023-24. The remainder of costs, and that includes, as I say, vaccination test and protect. The remaining costs are baseline into budgets. I know that vaccination will be on-going and now there is a new variant that has appeared, XBB1.5. As part of the vaccine programme in NHS Dumfries and Galloway, I was able to learn a lot about the vaccines and the different vaccines that were produced. Do you think that it is reasonable that the UK Government just terminated the funding rather than what you are saying phased it in a reduced approach that way? As I have already said, the argument not just coming from the Scottish Government but the Welsh and Northern Irish Government at the time was to phase that over a period of time. However, we have rehearsed the argument now and that is one that we have lost in a sense that the UK Government has decided not to continue funding Covid costs. To some respects, I am not often sympathetic to the UK Government, but it is a huge undertaking in terms of costs. Our difficulty is that we have essentially got a new infectious virus into our health system that requires vaccination periodically. It requires, to some extent, surveillance to test and protect and it requires some level of testing and so has costs associated with it that we are now having to, as I say, baseline into our budgets. That is very difficult to do. We will see how 23-24 progresses. Our big worry is that Emma Harper has already referenced. Our big worry is that if there is a new variant—and we are keeping an eye on XB, as she rightly says—if there is a new variant that has immune escape and greater severity of illness, we will need to take back up with the UK Government, given the implications of that. We saw during the pandemic that services were changed and redesigned and care was delivered differently. Digital is one of the issues that we saw people having their appointments digitally with whatever service healthcare provider is doing it. What cost savings would you foresee would be able to be achieved by looking at these service redesign approaches, including digital, for instance? I cannot put a figure on it just now, but there are certainly a number of drivers for looking at digital plus other reforms to the NHS. One of them is the demand on the services across the country. There is no getting away from the fact that people are presenting whether it is in primary care or secondary care—sicker or higher acuity, given the pressures that the pandemic brought to bear and the fact that they were not able to access services, particularly in the beginning of the pandemic, because we had to make really difficult choices to suspend or halt services or screening, for example. One of those reasons for reform and innovation is because of the demand that the system faces and will face in future years. The other is cost. We have to look at the fact that our health service is now £19 billion for the Scottish Government, which is a significant investment. The health service will continue, but, as others have said, simply putting more money into the health service is not going to necessarily help us to improve the services. It will certainly help us, but innovation has to be key. Digital has to be part of that. The BMA, for example, is one of the ones to call for a national conversation around the NHS. Whether we have a national conversation or we deem it something else or term it something else, there is absolutely a space to have a conversation with the public about how they want to see their health service respond to their needs in the future. What kind of reform do they want to see? I will make it absolutely clear that reform should always be within the founding principles of the NHS, not ifs or buts or maybes about that. Discussing on reform and innovation is crucial. I would like to ask a follow-up question about Covid testing. The free tests are no longer being funded by the UK Government. We have 1,200 patients in the hospital, I believe, at the moment with Covid. Do you think that the fact that our population is not freely able to test for Covid is having an impact on the amount of people that we are having in the hospital with Covid? It is a very good question. It is really hard to say, because it is difficult to determine, obviously, the patients with Covid in the hospital because of Covid, given where we are and where we are with community-wide testing. It is a probably a need-impossible question to absolutely definitively answer. We have to get to a stage—I think that it is right that we get to a stage—that we treat Covid in the way that we treat flu and other such viral infections. I can understand where people concern, particularly those who are caring for somebody who is vulnerable, who themselves are vulnerable or are immunocompromised. I can completely understand their nervousness, which they have expressed from the moment that we began to reduce community testing. As Emma Harper's question has alluded to, we do not have the funding from the UK Government to be able to continue that. Therefore, we have to get to a space where we have to treat Covid as we would, as I say, another viral infection of that nature. I will now hand over to Carol Mocken, who wants to ask questions around health and social care pay. The convener asked some general questions at the start around the allocation of pay in the budget. I would like to drill down into nursing and social care pay. At this committee on 15 November last year, Colin Pullman of the RCN described social care pay in the health service as, frankly, upsetting. He said that it is no surprise that we have a crisis in the social care workforce as well as the healthcare workforce. Responding to the cabinet secretary and the First Minister's briefing yesterday, Mr Pullman said that the RCN's previous warnings had not been listened to and ready to the point that fair pay is fundamental to the retention of the current workforce and attracting for the future. For the sake of the NHS and social care, can the cabinet secretary afford not to listen to the serious and real concerns of nurses given the numbers turning away from the profession? Does he think that nurses are being unreasonable? No, I do not think that anybody asking for higher pay and health or social care is being unreasonable. I hope for all the differences that we might have on this issue that Carol Mocken and others would recognise at this Government's approach to discussions and negotiations with trade unions has been constructive and meaningful. It is in stark difference to a number of other Governments across the UK, and it is why it continues to reiterate that, so far, Scotland is the only part of the country, only part of the UK that has not seen nurses and ambulance workers' staff going on strike. I am not taking that for granted, because we know that RCN, RCM and GMB continue to be in disputes and will continue to engage with them. On social care, in the budget 2324, there is around £100 million, which is part of the uplift for adult social care pay, to the real living wage rate of £10.90. Richard will correct me if I am wrong on that, but I understand that that is the same as the Welsh Government and that it has increased to the real living wage as well. That £10.90, for goodness, is higher than the UK Government's uplift, which is, I think, 48 pence lower than the £10.90 rate. I do not disagree, though, with the premise of both Carol Mocken's question and Colin Pullman's comments. We have to continue to see what more we can do to improve pay terms and conditions for social care workers. That comes, obviously, at a cost. I know previously that Carol Mocken and the Scottish Labour Party have called for, for example, an increase to £15 an hour. I would love to give £15 an hour yesterday to our adult social care workers, but that comes at a significant cost of well over £1 billion additional, which would be very difficult, if not, well, near impossible, frankly, to fund, given the financial pressures that we are under. We have to keep working at this, and I certainly would not see the uplift or the real living wage being the final uplift that we see. I think that we will continue to progress in that regard. Can I come back on social care and ask, when you have been doing your budget deliberations, have you talked at all about moving towards collective sectorial bargaining and the fact that we know from the trade unions that they are saying that this one change could make a significant difference to retaining staffing, which would then in itself help to look at budgeting across social care? Yes, sectorial bargaining, as you know, is part of the national care service proposals that we put forward. It is there on the, as you know, is part of the proposals in that respect. It is very difficult to do in the current structure, and we are always looking to see what we are able to do. Given that we have a very fragmented landscape, independent providers, third sector, obviously local authority providers, we have a very fragmented landscape right across the country. That sectorial bargaining has been virtually impossible. It is very difficult thus far, but it is certainly part of the national care service proposals. If we can do it outwith the national care service, it is certainly something that we are looking at around our fair work agenda in relation to social care. We will certainly do that, because I think that there is strength in sectorial bargaining. I have one final question just in terms of when you looked at your finances and budgets, what consequences do you think there may be in terms of having to fund the introduction of the national care service, and how do you see that in the sort of close and then slightly longer term for pay terms and conditions? I think that that is a really fair question. As per my previous answer on that, we are obviously looking to produce a revised financial memorandum that will produce to the finance committee, as per their request. What I would say is that the amount that we spend on the development of the national care service will be as a fraction of the overall health and social care budget for the financial year coming. We have said that if you take the current financial memorandum, it should keep me right here, but between £63 million to £95 million out of a budget of £1.2 billion in terms of health and social care. We are really talking about it, not an insignificant amount but in comparison to the entire budget, a small amount. We will make sure that we do not lose sight of improvements that need to be made right now to social care, not waiting for the NCS. The second thing is that one of the driving forces behind the national care service is precisely to improve pay terms and conditions, sectoral bargaining and ethical commissioning, putting that all at the heart of the principles of the national care service—you can see that on the face of the bill. That is going to make a big difference to the sustainability of social care in the future. David Torrance Cabinet Secretary, is it realistic to expect a shift towards preventive spend when the immediate pressures and demands on healthcare are currently so great? I think that we can afford not to. We just can't. Given the scale of the pressure we are under, we have to be focused on both the preventive as well as dealing with the current demand. Especially over the past few weeks, it has been exceptionally exhausting for our healthcare workers, whether they are in community primary care, secondary care or utterly exhausted after a really difficult, relentless, almost three years of a pandemic. I understand that point and why David Torrance asked the question, but part of the solution has to be on the preventative. We have to make sure that we are doing everything that we can, whether it is in relation to smoking situation, drugs, alcohol or obesity. I have mentioned asthma, for example. There is a lot of focus still going on the preventative and mental health preventative space as well. You will see that in the 23-24 project. I can give you examples of where we are spending on the preventative. I am very keen that we do not lose sight of that, even with the pressures of the current demands that we see on the service. To provide specific examples of how a preventative and proactive care programme has informed spending decisions, I know that you have given some there, but how good is it at making those decisions? It is one of the reasons why that programme exists so that we do not lose focus on the preventative spend. It is not just about the health and social care portfolio, which is really important. We will take a preventative look through our entire budget, whether that is through oral health, through some of the smoking cessation, obesity, so on and so forth. The Deputy First Minister will bring the cabinet secretaries to the table regularly to talk cross-portfolio. What can we do around the preventative space in that regard? We all know that social economic determinants can determine poorer outcomes for health. We have to focus in on that as well. So, taking the whole family well-being fund or other funds that are focused on reducing poverty, they are going to be crucial in the health and social care portfolio, and they will play a part in that. Thank you, convener. I wonder if I can return to the point about pay for the social care workforce. We have heard of a variety of evidence in the committee in recent days that pay could really make the change in terms of retaining people within the system, because we know the challenges that exist, particularly when social care workers can earn more in Lidl, for example. Has the cabinet secretary done any cost-benefit analysis of what the change and the difference made to the NHS would be in terms of attendance at A&E, daily discharge, if we were to move to a position of £12 an hour, then looking to raise that £15 an hour in the course of the Parliament? The analysis will be done on a very regular basis, because I do not again disagree with the fundamental premise of Paul O'Kane's question, which is that if you pay people better, then you have a better chance of both recruitment and retention. We believe in that. What we can't do—so notwithstanding that he and I completely agree in the premise of the question, what we can't do is take money out of the health service, because we still need to deal with the demand pressures that we have in the NHS. We can't just take £1 billion out and say, right, we're going to put £1 billion in here and because we think that that's money better spent here. We'll do that to an extent, because that's the entire point of budgeting, but I couldn't justify taking the cost of £15 an hour, even to help an hour initially at the moment, away from the NHS and into social care. I'm very keen to work with local authorities, very keen to do what we can to continue to increase—excuse me—pay where we can, but it's not just about pay. Pay accepts fundamental, something around terms and conditions and the social care workforce, career progression and the social care workforce. If there's more that we can do in that space, I'm absolutely up for it. Yes, this is always part of the calculations and analysis that we tend to do, but I don't think Paul O'Kane would suggest—maybe I shouldn't put words in his mouth, but I don't think it would be a suggestion to take the cost of what it would cost us for £12 an hour out of the NHS just now and put that into social care, because it would have a very significantly detrimental impact on the NHS at this stage. Given the acute situation that we find ourselves in and the announcements that the cabinet secretary will make later in this afternoon, that piece of analysis on the benefit of increasing pay is something that should stand alone and be done by the Government. I'm keen to understand that the cabinet secretary intends to make an announcement in further detail about the beds that he will purchase in care homes. Those will require staffing elements. We know again about the staffing challenges. I think that it's not just that, because obviously there are care at home staffing issues, and I agree with him on terms and conditions. My sense from his previous answers is that again, we're in the four years down the line, a national care service will deliver all of this and we can move the dial. Does he not accept that we need to do more now and that we need to look at these issues right now instead of wishing them away, if you like, into the national care service? I certainly disagree with the cabinet's analysis of the question, because I've made it very abundantly clear that we don't intend to wait for the national care service to make improvement. For the time that I've been health secretary, we've been at three pay increases, £10.02, £10.15 and £10.19 in terms of £23.24. We're not waiting for the national care service to come into place to continue to uplift wages where we can. That's absolutely got to be a part of it. I don't really have anything more to add that he and I haven't already rehearsed, but I think that if people are going to call for a wage uplift, which they are perfectly entitled to do and with good reason, they've got to do that within the context of a fixed budget. Every single penny of the £19 billion in my budget has been allocated. If you think that there should be an uplift in £23.24 to £12 an hour, then you've got to be able to spell out where those hundreds of millions would come from within that fixed allocated budget. Bearing in mind, we've made really difficult tax decisions as well, which I stand by full square, because I think that those who earn more should be paying more for strengthening our public services. I suppose that following on from that point, and the cabinet secretary's outline is 48p lower than that pay rise this year to care staff. Within the national care service evidence that we've heard in this committee around the bill, there has been a lot of criticism about the process, about this being focused on a structural change. He's already referenced the financial memorandum and the commentary of the Finance and Public Audit Committee. Does he not acknowledge that this would be the opportunity to pause on the national care service bill to take account of all of that criticism and to look at how do we deal with these immediate pressures in this financial year and then make a plan going forward that brings all those partners on the table who have those significant criticisms? A couple of things. You kind of fleetingly mentioned a 48p pay rise. I think that it's just worth me coming back on that slightly, because the pay rises over the last two years, since 2122, means that adult social care workers that we have given an increase of £2,380, accept high inflation costs and so on, have meant that the cost of living crisis bites, but it's not £2,380. It's not an insignificant up-lift 12.7 per cent, so it's important to put it in that context. On his substantial question, I have said publicly that I'm up for a discussion about the re-profiling and re-phrasing of the national care service. I don't think that has to impact the NCS bill. The NCS bill is a framework, it's an enabling bill. It's there to create the foundations of the national care service. The care service will not be fully operational in current plans until the end of the parliamentary term for good reason, but if there's a discussion to be had, both my door and my inbox is open. If Paul O'Kane, the Labour Party or any political party in this table wants a discussion on the re-profiling and re-phasing of the national care service, it's certainly something that was indicated to me by trade unions who I met just before the festive period who wanted to discuss the re-profiling element or re-phasing of the national care service. I did say to them that I would consider it and I will do that, so they've given me some of their concerns in regard to the national care service, but I'm genuinely up for a discussion. Anybody who proposes any re-profiling of the national care service has to make it clear for what purpose and what benefit, as opposed to simply just being seen to kick it into the long grass. I'm trying to be constructive and helpful. I'm up for a discussion in that respect. I will convene in that vein of being constructive and helpful. I don't think that it's a surprise to the cabinet secretary given that I've called for a pause in our robust discussions in the chamber and elsewhere for quite some time, but that is welcome if he is willing to have that consideration. I hope that he will respond to, certainly as I say, the cause of trade unions, front-line staff and others who are calling for that dialogue prior to getting into legislation going through its stages. I have questions from Stephanie Callaghan, followed by Emma Harper. Thank you very much, convener. I know that you've touched on this already this morning, cabinet secretary. I'm wondering around targets. Existing targets so often define what our priorities in the focus are. What we're measuring is where the focus is. Are you reviewing the targets that currently exist and considering alternative targets? Can you give a couple of examples of successes? On the latter point, we have a number of commitments targets that we're committed to in our manifesto. When it comes to social care spending, our investment by 25 per cent increased over the course of the Parliament. We're well ahead of trajectory to do that, so I'm very confident that we'll meet that. Social care spending will increase by more than £800 million in 2023-24, so we're well ahead of our trajectory to increase that spending by 25 per cent. Excuse me over the life of this Parliament. We've also promised to increase mental health spending, 25 per cent increase to mental health spending and to primary care funding and half of all front-line health spending going into community health services. I'm talking about a preventative agenda. I looked at the half of all front-line spending going into community health services in 2020-21, the last year for which data is available. 49.6 per cent effectively 50 per cent of spend was in the community compared to 50.4 per cent, so we're almost there. I'm confident on the increase to mental health spending as well. There are many targets that we're committed to over the course of our manifesto programme for governments, which I'm confident of meeting. There are always targets that we'll keep under review depending on how pressured our health service is at any given time. I think that I'll be giving a false impression if I didn't say at this stage that the pressures that we've been facing over the past few weeks—health boards, for example—have had to take really difficult decisions around reducing some element of elective care, but that's clearly going to have an impact if they're not able to make that up in future weeks and months in relation to planned care targets. There'll always be targets that we'll keep under very, very close review. Obviously, if there was ever any change in target at this committee, we'd be the first ones to know. In today's budget scrutiny session, I'm interested in picking up on what David Torrance started with about prevention. I know that cross-portfolio budgeting happens, and a lot of health and social care budgeting goes directly to local authorities. It sometimes goes to third sector. For instance, I'm thinking about work that I've done with the eating disorder charity beat, where £400,000 was received from the Scottish Government to support work to help to support people with eating disorders. I'm interested to know, because the budgeting goes to other places like local authorities, £35,000 goes to each local authority to look at developing an autism strategy. Does that make it difficult to track and evaluate the effectiveness of the funding because the health and social care budget goes to other places? It comes with challenges for sure, but it's the right thing to do. Hema Harper and I have both agreed that the value of a third sector is enormous. We've seen that pre-Covid, but certainly in the course of Covid. If I gave you just a couple of examples, when we look at oral health, we have a really good partnership or a project that we fund eat well for oral health. It's a relatively modest amount of funding, but we have two third sector organisations working with the NHS to deliver the programme. We've got Edinburgh Community Food and LinkNet mentoring, which I think are known to many folk around the table. We've got this oral health improvement model that uses food, that uses nutritional skills, as a medium to remove barriers, promote cultural understanding and dental services among families that are affected, particularly with socio-economic and racialised health and equality, so it's a really good project that has a real-life impact on the ground. We're able to monitor the impact of that project. One area that we've not really touched upon in discussions and committee—maybe I'll be coming up obviously—is investment in our community's mental health and wellbeing fund for adults, which is £36 million that has been provided over the past two financial years as a result of thousands of wars and thousands of them. Community projects have focused very much on prevention and early intervention when it comes to mental health impacts. We can come with challenges in terms of monitoring, but we've got to first have faith, as I do in our third sector partners, but secondly, we've got to make sure that the appropriate monitoring and so on governances around any distribution of those funds. Just a final wee one about the cross-portfolio issue. Just before recess, Minister Richard Lockhead took a question in chamber about helping support employability gap with people with autism. That is a reflection on cross-portfolio requirements to support budgeting as well. Sometimes it's difficult to trace where that specific budget comes from. Is it yours or is it education and skills, for instance? I know the complexities of how we're trying to peel apart the budget is something that's interesting to me, but that was a cross-portfolio issue that I just wanted to raise. Not much to add. The cross-portfolio working has been in government for over 10 years. We've always been encouraged to work cross-portfolio, but I can certainly say in the DFM's role this term of Parliament that he's really made sure that any hint of very siloed working or compartmentalism is quickly sniffed out. We are working exceptionally collaboratively. There are lots of examples that we could give. Emma Harper has mentioned a couple already. The Glasgow Pathfinder set out in the tackling child poverty delivery plan is another. There are numerous examples that we could give, but I agree with the premise of your comments for sure. I'm going to let you continue, because you had some specific questions around mental health spend. Yeah, sure. The Cabinet Secretary has mentioned the mental health spending with the children and adults, the wellbeing community funds. The Cabinet Secretary has mentioned that already, but I am interested to hear about how we can continue to monitor and support whatever input that can be made for mental health funding in Scotland, because we know the challenges for our healthcare professionals, for instance, as well as for everyone else. I'm not sure if the Cabinet Secretary really needs to comment any further about that, but I'm interested. That was one of the specific funding aspects about supporting people's mental health in Scotland. I hope that our 23-24 budget restates our commitment to mental health support. If you looked at it in regards to previous years, we are up 6 per cent on 21-22, spending up 139 per cent on 2020-2021. There has been a significant increase in mental health spend over that kind of three-year period. I think that there's little for me to add to what I've already said, but the focus has to be on that preventative, for sure. As we know, each of us, as members of the Scottish Parliament, there still exists a significant challenge around backlogs for access, particularly to CAMHS and other mental health services, so our focus continues to be in this budget as a demonstration of that, trying to do our best so that people can get seen, particularly our children and adolescents and young people in a timuous fashion. In our briefing papers, it talks about new models of primary care in order to address specific issues such as mental health, for instance. Do you think that that will be beneficial because, if we are looking at GP practices, for instance, having mental health support workers embedded in GP practices, that is something that should be able to be successful as we are approaching how we tackle our mental health issues? It depends on what we read by looking at the models of primary care. At the moment, I am not looking at fundamental reform of the independent contractor model. We are with the contract. I do not think that that would be the right time to upend that entire independent contractor model. All that being said, I am really up for the national conversation around our health services and reform of those. In terms of the model of general practice, we have seen a change over the years. Sanders-Glennie referenced the kind of multidisciplinary teams that are and allied health professionals that are there in GP practice. We saw them, of course, over a number of years, but there has certainly been a significant increase in the amount of health practitioners within a GP practice from your physio right the way through to your advanced nurse practitioners and so on and so forth, all contributing towards a general practice model. One of the key innovations of this Government has been that community link worker and mental wellbeing worker. I have a fantastic community link worker in my constituency, and I think that any of us that have interacted with community link workers know just how impactful they are as part of that general practice team. We will continue to invest in those additional members of staff within a general practice that are part of that more holistic approach to primary healthcare delivery. If I may, I would like to ask a question about alcohol and drug services. We have seen that this budget shows a 13.6 million increase. That is equivalent to a 12.3 million yield times increase in tackling alcohol and drug problem use and the effects of that. However, it can be quite difficult for the Government to ascertain the effect of that, because a lot of it is delivered by alcohol and drug partnerships. Is the potential for these services to be brought under a national care service, might that be a vehicle for knowing how that money is spent and in what areas it can be spent better to get the health results that we need from that? I was taking the second part of the question first. There is a genuine discussion that has been had about alcohol and drug services being part of a national care service and the pros and cons of that. I can see the argument from those who oppose that as well and have some concerns around that. That is why we are taking some time before we make any decisions in regard to number of services under the national care service. We are doing research, working with external stakeholders and so on and so forth. As I said, the current plan is not to have the national care service for the operational tool at the end of the parliamentary term and it has already given public commitments around entering into discussions about the hearing from political parties and external stakeholders around whether that timetable they feel is the correct one. Notwithstanding all of that, without putting words in my colleague's mouth, Angela Constance, who I speak to, as you can imagine on this issue very regularly, we have some excellent ADPs across the country doing some phenomenally good work. Angela's role is so important because we are able to have that national oversight on what is working on the ground and what is it. Of course, the lack of consistency was one of the reasons why the matter standards were brought in. You can bet your partner that it would be no surprise to you that Angela is all over that with every single ADP and all the partners involved right up and down the country. We have the RAG status. We know who is doing well and what matter standard, how far away they are from whatever standard. Angela will certainly keep that close governance and monitoring of that. On the 23-24 budget, part of that increase is an additional £12 million to deliver the cross-government plan, which will be published early in the new year. It speaks to the point that Emma Harper was making about that kind of cross-government portfolio working. I have been contacted to ask you a question and I am just going to read it out to you. Can you please ask the Scottish Health Secretary who is going to do the 1.5 hours that they are proposing to cut from my working week as part of their proposed pay rise? We are a small group of specialist nurses. This cut means that we will lose around five working days each month from our team. At a time when we are on our knees, they are putting more pressure on us by expecting the same work in less time or just taking advantage of goodwill of nursing staff. I thank the individual who asked the question. First of all, I should say that the reduction in the working week is one of the issues that was brought forward by trade unions. Our meaningful engagement that we have with trade unions is a regular meaningful engagement as part of the pay negotiations. That was a fundamental issue brought forward by those who represent the workforce, not something that was necessarily proactively brought forward by the Government or indeed by employers. We thought that it was important to listen to the trade unions, and that is why we have made a commitment to the reduction of the working week. Clearly, the reason why we have not said that we will do that by tomorrow or by next month within the short and narrow timescales is precisely the reasons that the individual who has contacted you has highlighted. We would have to look at what the implications are for staffing and what I would give a commitment to as we are committed to continuing to invest in our workforce. That will inevitably mean growing our workforce as well. If we are going to reduce that working week, there is no doubt that we have to look at filling some of those significant vacancies. I will be the first to admit that there are significant vacancies within nursing and midwifery. The individual who has asked the question, I hope that they can take some reassurance that we are going to work through the detail before we implement a shorter working week. That has got to understand what the workforce, what the demand pressure would be, what the impact would be on services, and making sure that we have adequate staff in response to that. Finally, what timescale will that be over? We have not defined the timescale yet because, for exactly the reasons that the individual who has contacted you, there are some real complexities that we have to work through. Employers are committed to sitting down with trade unions ASAP to work through some of the detail of that. Once we have those timescales, we will obviously be transparent and open and public with them. That seems to be all our questions. I want to thank the cabinet secretary and Richard McHillam for their time this morning. We will look at evidence on three public petitions that have been given to us to look at. The cabinet secretary will provide evidence also on an affirmative instrument, so we will see you next week. That concludes the public part of our meeting today.