 Good morning and welcome to the 26th meeting of the Health, Social Care and Sport Committee in 2023. I've received apologies for today's meeting from Stephanie Callahan and David Torrance, and we're joined by James Dornan MSP. The first item on our agenda is to decide whether to take items 47 in private. Are members agreed? Agreed. Thank you. The second item on our agenda is a session as part of the committee's pre-budget scrutiny ahead of the publication of the Scottish Budget for 2024-25. For this morning's session, I welcome to the meeting Carmen Martinez, co-ordinator of the Scottish Women's Budget Group, Professor David Oaf, commissioner of the Scottish Fiscal Commission and Philip White, director of IPPR Scotland. We will move straight to questions. Tess White. Thank you, convener. My question for Professor Oaf, please. The SFC has projected that health spending will increase from 35% of devolved spending in 2027-2028 to 50% in 2072-73. My question is, what actions can the Scottish Government take now to stop that from happening? Thank you. Let me just make two points. First of all, it is not our role as a commission to advise the Scottish Government on policy. We simply produced a forecast of what likely spending and tax revenue would be, and any decisions about policy are for MPs and the Government to make. It would help to talk you through some of the drivers behind that growth in the share of spending. What we are projecting here is that spending on health will grow faster than other elements of spending over that 50-year period. There are a number of factors behind that projected growth. One factor is that, because of technical progress in the rest of the economy, that will drive up wages. In the health sector, a lot of the technical progress that takes place is not specifically reducing the manpower inputs into work. Some of it does so if you replace normal surgery with keyhole surgery. That means patients have to be in hospital or less long. That means there's less cost involved in looking after them. But a lot of the progress that takes place in the health sector is about developing new techniques to solve previously untreatable conditions or to improve the treatment of other conditions. The problem is that you still have to pay the doctors and the high calibre nurses you are employing wages that match those that are in the private sector. Your costs of hiring the labour are going up, but you are not getting the benefits of reducing the labour inputs into the process. That's one factor driving the increasing costs. Another factor is simply that, as you make, through new discoveries and new technical progress, new ways of treating people, you will be treating conditions that you previously weren't treating. The amount of treatment that you will be doing will go up for that reason. That's another factor driving up costs. A third factor is the increase of chronic conditions like obesity, diabetes, etc. For example, there were forecasts produced by the Institute for Physical Studies that said that the growth in people with a chronic condition has been grown by 4%, which is higher than population growth as a whole. The higher fraction of the population are suffering from at least one chronic condition, but the number of people suffering from multiple chronic conditions has been growing by 8% over time. So the number of people with chronic conditions and multiple chronic conditions has been growing, and that's another factor driving up the costs of health spending. A fact to which you might think we'd be driving up might be demographic failure. So what's happening in Scotland is that, in common with many other countries, we have an ageing population, but we also have a declining population, which is less common. So what's been happening in the past is that the Scottish population has been growing because the declining birth rate has been matched by increases in immigration. But now the decline of birth rates has got to the level that has not been matched by immigration. So we're projecting that over the next 50 years, the population in Scotland will actually be falling. And the way that pans out in terms of health spending is that the ageing of the population will be driving up expenditure on health in the earlier parts of that 50-year period. But then towards the end of that 50-year period, the fact that you've got falling populations will turn to reduce the rate of growth of health spending. So the demographic is playing a small part, but it's playing a part of increasing the growth in spending early in the period, but reducing the growth of spending later in the period. So if that helps you to understand the forces that are driving it. Thank you, and on that figure of 4%, seems a very important figure. The SFC's fiscal sustainability report helped to inform the Scottish Government's decision to apply a higher growth rate of 4% to health and social care expenditure. In your view, and given the wide-ranging pressures on the NHS, is the 4% high enough? Again, let me just repeat, we do not comment on policy whether it's the right policy or the wrong policy. Our role is simply to advise the Government on what the spending and tax consequences are of its policies. I'm sorry, I can't help you further. That's fine, and I'll go to my final question for Philip White, if I may please. Audit Scotland has highlighted many times that the NHS is not being run in a financially or operationally sustainable way, even before the Covid-19 pandemic. So the question is, do existing resources need to be deployed differently or more effectively in your view? I want to make sure my microphone is on. Thank you, I suppose I could come back to your first question to David and answer in that one as well. Ultimately, I think what this all comes down to is preventative spend. We're more in the decade on from Christie, and yet ultimately the vision that Christie set continues to be an ambition rather than actually being meant to be making back to prevention at some point. As David said, I think he's helped set out the drivers quite clearly, but we know that Scotland's population is due to decline over the next 20 years, but also over the next 20 years you're going to see a corresponding increase in the annual disease burden. So we are getting sicker, we're getting older as a population, we're getting sicker, and as a result of getting sicker we're also getting poorer as a nation and again making back to some of this. So that's ultimately where this driver is coming from, that we are still continuing to deploy resources to deal with the consequences of quite often preventable and amenable mortality and preventable disease. And that's the situation we're stuck in, we're constantly deploying reactive spends to things that could have been proactively addressed much earlier. So while the resource is right now within the system, I think the other thing we might come back to is obviously workforce and staffing. We know that a huge proportion of health board budgets and operating costs are taken up with staff costs, and indeed that's where a huge chunk of obviously the increases over the last couple of years in particular have gone. Staff are our biggest asset and resource, so I don't think that you'd say that those resources aren't being deployed in the right way, but clearly if you want to continue to grow the workforce that's going to add increased burden and increased pressures onto the budget. So I'm not sure I've actually given a good answer to your question there, because you're into then how hospitals and health boards are deploying resources and that's probably beyond my area of expertise in terms of how they're deploying every pound in penny. I think the overall summation is that going back to that point, we need to continue to put additional resources in because there are huge pressures that have built up in the system. Those are pressures that existed long before Covid, albeit that might have exacerbated it, but there are also pressures that at some point we have started to shift our resources into a preventative spend model. You have the huge potential to ensure that they didn't come to pass. Thank you. I'm now going to move to Carol Mawkin, who joins us remotely. Thank you, convener. I'm interested following on from the discussion that you've had there about preventative spend. I suppose one of my questions is, is there enough being done to achieve transformational change in the service, considering the financial instability that the health service is in? If you may be able to follow on from that. Just for the panel, you don't need to press your button. That will be done by Broadcast. Okay, thank you. Good morning everyone. The Scottish Women's Budget Group has long called for greater investment in the care sector particularly, and for care to be placed at the core of economic recovery after the pandemic. Our asks, in a briefing that we published at the beginning of the year, our ask go beyond plans established in the National Care Service Bill 2022, because we argue that higher wages and expanding workforce are key for staff recruitment and retention. We also consider that greater investment in care is crucial to meet current amenities with a focus on quality as well as on prevention. So when we modeled this course of care in Scotland, we took into consideration who needs care, the intensity and type of care provision and how much care costs, including care workers wages. By looking at these areas, we identify a core scenario that we thought is the bare minimum or a base that we should build from. However, the modelling goes further to presenting a transformative investment scenario as required to re-envision and reconfigure care in Scotland. So this is where I'm addressing the question. So the core scenario, which focuses on ensuring current substantial needs are covered by increasing the number of care recipients by about 20%. And this would meet current amenities and extend free provision to all types of care, so including household tasks. This core scenario also aims to increase pay rates to the more competitive wage of £12.50 an hour. And the model estimates that this would cost £5,094 million in 2020 to 2023 prices, which is £1,500 million above the current budgeted level of net spending on adult social care. The transformative scenario though, so we said that this would be the minimum that we would like to start with or the base, but we should work towards a transformative scenario. And the briefing that we published sets the path to achieve this transformative scenario. And that would focus on increasing access to free care to those with moderate needs, as well as increasing qualifications and paid to Nordic levels, with care workers paid an average of £15.21 per hour. And in this scenario, higher take-up rates are assumed that would relieve informal care needs further and eliminate unmet needs. And this would require £6,822 million in annual public investment or 3.7% of GDP, 1.8% increase on the current budget. That is nearly doubling public investment in care. One of the reasons, there are different reasons behind why we think that this investment is important. One of the reasons is we think that this would lead to greater gender equality outcomes, 83% of the workforce in the care sector are female. So higher wages would create more gender equality outcomes and it will help with recruitment and retention within the sector. We also think that this is important to comply with fair work. And there was another reason behind this and I just forgot about it, but how it will come to me. Can I come in? Yes. I really appreciate the information that you've given us. My question would be given the pressure of post-pandemic backlog, the transformation into the potential for the national care service. Do you think that it's realistic that we can do that in a single-year settlement or do you think that we need a multi-year settlement? Is there other things that we need to do to achieve that? Thank you. I remember what I wanted to say and is that another reason behind why we should invest more on care is because of the preventative approach by looking after people before they get very sick. That should prevent lengthy stays at hospitals. So again, that would alleviate pressures on the NHS. Looking at the customs, our forecast will certainly help, but perhaps we need to ask ourselves if we can afford not to do something about it or if we can afford not to invest in it. I wonder if I could ask one of the other panel members just about the way in which the settlements happen and whether that is put in. The boards are definitely telling us that they foresee problems in meeting their current requirements, so do you think that if we had a different approach that that might be helpful? Two things. We know that multi-year budgeting helps to cross a huge range of organisations in terms of planning, in terms of being able to figure out where you're spending your money long-term. That's really good to bring it back to the elective backlog, which you mentioned. I think that's a prime example. We know that, obviously, the targets that the Scottish Government set in the terms of recovery plan across both inpatient and outpatients still aren't being met, so we still have huge amounts of people waiting longer for elective care. I think it was all at Scotland that rightly flagged it. There was some concern about just giving the time scales, which are partly understandable that the recovery plan was put together, the extent to which boards had a say in terms of how those targets were derived. But equally, those targets were national level targets. Overall, this is how much we want capacity and output to increase at a macro level in Scotland by 2026. But we know that, again, things like waiting lists have huge variations across the country, across health boards, across specialties, across everything. So being able to derive a national level target without knowing how that would be delivered, by who, where and when at a local level obviously shows a huge disconnect. If you then remove funding from that and have a disconnect on how much money health boards will have each year, that makes the job even more difficult. I think just on something like that, it shows that rather than having a national level top-down approach, actually having a bottom-up approach where you can start to determine what your capacity and need is at a local level, and then in turn what funding is required to deliver that over a much longer period, is how you ultimately arrive at being able to meet those kind of long-term outcomes, rather than an annual cyclical basis. I've got one last question, convener, if that's help, okay. The first speaker mentioned sort of a use of technology. There's something that's repeatedly brought up with the committee as sort of digital, and our capacity in terms of digital, speaking to each other, and obviously as well just the investment we need in that. Do you think enough has been done by government to try and support health boards with that? Again, that's not something which was in our capacity to talk about. If I could just explain what we do in the physical commissioners, we produce budget forecasts. For those budget forecasts just cover the revenue from devolved taxes, primarily the Scottish income tax, the savings non-dividend income tax, and we also forecast spending on social security. We do that both for the one year ahead budgets, one year ahead forecasts for the budget, and also in May each year we produce a five year forecast to look at some of these issues about how you plan spending over a five year period. But again, that doesn't cover health. The only time we've actually done any projections on health spending was for the physical system ability report, the first question I was asking about. So we don't get into any details of modelling and forecasting health spending. So some of these more specific questions about technology that you're asking about are not things which we actually have the knowledge and expertise to advise you on in any detail I'm afraid. No, thank you very much. Thanks very much to the panel for their contributions so far today. We have discussed pay pressures in the NHS and general financial pressures. The Scottish Government agreed to pay off for 6.5 per cent from most NHS staff for 23, 24, and particularly a 12.4 per cent increase for junior doctors, but nonetheless pay pressures, payroll pressures continue to persist as a structural issue and challenge for the national health service. Mr White mentioned that wages do take up a lot of spend, but it's about balancing that whilst also recruiting new staff and retaining staff who may bleed overseas or to external agencies, for example. How do we strike that balance? Is there any insight you might have about how well current boards are performing in that regard or indeed national pay bargaining is performing in that regard and how it's potentially structurally adrift from where we need to be? I'm afraid in the substance probably not and definitely probably wouldn't want to cut across while I'd imagine it would be a very robust answer that trade union colleagues would give you as they definitely don't want to step in their toes. The general point stands, so it's just over two thirds of operating costs taken up by pay. Again, as I said before, that is not unexpected staff for our biggest resource, our biggest asset. It's understandable and it's right that we ensure that pay has been able to match that we can recruit and retain the absolute best staff. By then it becomes a question of what does that leave left over for the wider work that needs to be done and is the balance right? If we think that it isn't, then I don't think the lesson that anyone would take from the last couple of years in particular is that you look to restrict staff numbers or just pay. It's at the other end of the scale those non-staff costs need to increase to make up the balance. That's helpful. Do you have any insights at anyone on the panel on how this is benchmarked against other healthcare systems in the developed world, perhaps? A different point in answer to your question, which is about how these pay increases will get funded. A lot of this depends on what happens in the rest of the UK because health is a devolved spending power. A lot will depend on the Barnett consequentials that flow from whatever settlements are made by the UK government. So if the UK government settles roughly the same levels as the Scottish government and if it does that by increasing budgets, then all that will flow through to Scotland through the consequentials. So the net impact on the Scottish budget could be quite low. But if the UK government settles as much lower level than the Scottish government has done, or if it chooses not to increase any funding, it just says we will fund the site of existing budgets, then there will be very little increase in consequentials. So all the pay increases agreed in Scotland will have to fall on the Scottish budget. So the way this is going to impact on the Scottish budget will depend to some extent on what happens in the rest of the UK, what levels they settle at and whether they increase budgets in order to pay that increase in wages in the rest of the UK. It's just something to bear in mind when you're thinking about the year ahead and the budgeting for a year ahead. Did Ms Martinis have a point to make? Did you have a question about benchmarking with some countries? I just thought that you were just about to come in. No, no, no. Sorry, we're not. Sorry, if you can meet him. Thank you. It's just more of a general point, I should say. It's not a response to any particular question, but I think there's probably a wider point back. Because it brings us together the discussion we've had on preventative spend, discussion on staffing, which is the balance of what we're putting on resources. So if you just take staffing over the last five years, the NHS Scotland workforce has grown by over 12%, that is understandable to be expected. The corresponding increase in the GP whole-time equivalent over the last three years, with different time periods, is a decrease of 3%. I think it speaks to a wider point that we talk about the health service, but actually what we're quite often talking about is secondary care, which continues to dominate the debates, dominate resources, dominate attention. Whereas actually, if you want to talk about shifting to a preventative model, actually primary care in community health is where you see the biggest returns. I'm constantly got a GP in the room, so we may come back to this at some point. But I suppose it's just more of that general point that there is a continued domination of secondary care, which again is understandable to where some of the most significant pressures are. But just in terms of that staff resource, funding resource, everything else, actually you can see that that balance of where we're delivering care is still very much stuck in a secondary first model, rather than actually starting to look at what we can do to bolster the role of primary care. Which means you start to think about health inequalities, about tackling diseases before they take root, and those wider social prescribing, social issues. Actually again, that's where you see some of your greatest returns. Can you just ask us a follow-up about the potential consequences of capital investment as well? Do you see an issue with capital investment versus productivity enhancements vis-a-vis labour intensity in the system? The capital programme is again an area that's not within my expertise. No problem. I'm going to come to Emma Harper for a supplementary on this issue. Thank you. It's for Philip White. Just going along with the conversation, I've got bits of paper in front of me about preventative approaches. I know Henry Dimbleby's written a lot about ultra-high-process foods. The work of Professor Pekka Puska in Finland reducing the mortality of people by a whole-system approach, getting restaurants, cafes, supermarkets involved in providing healthier choices that are affordable for people. I'm thinking about preventative spend rather than just secondary care, fighting fires, constantly. So something has to shift with the way we invest to stop folk getting into the hospital in the first place, to stop people being sick. Our non-communicable disease paper that came out, it's a cross-party approach where colleagues, Gillian Mackay, Kara Mokhan and Sandesh Gullhane and Foils of Childry, we've been part of this cross-party approach to look at non-communicable diseases that contribute around 53,000 deaths in 2022 in Scotland. Something needs to be done differently. What would you suggest we cut out something in order to move funding to preventative spend? There is only one pot of money and it's a real challenge to figure what we need to do differently. So this is some context. We did some analysis earlier this year looking at the social and economic harms of poverty. So we looked across a number of public services but also looked at the economic impacts. Just within health boards, so not even the wider health budget, just within health board spending, our analysis indicated that around £2.3 billion of health board budget is responding to the consequences of poverty. So that is in things like higher affordable disease, mortality and everything else. So huge amounts every single year are going in. But you've hit a knee on the heads, whenever we've released that report, the question everyone asked was, where will this money come from? Because there's a seesaw that every point that you put into preventative spend is a point that you have to take from somewhere else. But I think it's back to long-term budgeting, multi-year budgeting, that we've been having that debate about Christy for more than a decade now. So that's more than a decade of time that we have lost on starting to shift that balance. So if we had started at that point, actually again you'd be saying huge returns today. So it's really tricky and I don't have an answer of where you start to put that money in. The one I always come back to is that you've got a commitment to put all health consequentials into frontline health spending. But that can range that some years, that is hundreds of millions if not billions, some years it's low hundreds of millions. So if you're talking a couple hundred million in health consequentials, putting it into the overall health budget, actually it's a tiny drop in the ocean. If you took that money and put it instead into something like getting every homeless person off the streets in Scotland, something that actually has a direct impact on people's lives, things like that can have a huge contribution towards starting to tackle those long-term health inequalities. But I think that's the problem and I think it is potentially again that dominance of secondary occur in the debates that we have. And again it's understandable given huge pressures and backlogs that exist in the system. Absolutely every spur, penny and points can absolutely be directed at fighting that backlog and tackling it and bringing it down. But I do think we missed that opportunity to start thinking about actually, if we started putting our money into homelessness, into social security, into good quality housing, those are all things that we know have that long-term and direct impact on those health inequalities that continue to blight Scotland, that continue to see those huge variations between the most and least deprived areas. So it is incredibly difficult but it's one of those ones that you need to start at some point and the longer we put it off, we know how much more likely it is that those inequalities continue to persist and those projections around avoidable mortality and communicable disease and everything else come to pass. I know we're probably going to come to poverty and tackling poverty but do you think there's a role? We have certain things that are reserved to UK government, there's items that health is devolved but the money isn't. So I'm interested in also what role do food producers and retailers have in engaging with government to look at how we support having a diet that are more, I suppose, more healthy so that people can afford healthier food instead of the way that some of the food is marketed right now, like processed food, which is jam-packed full of calories, which doesn't tell your brain that you're satiated so you keep eating. So there's some emerging research around this that I find pretty fascinating but do you think there's a role for supermarkets and restaurants and cafes to work with government in order to help deliver a less obesogenic environment? I think there has to be and again so this is where I quite often, and it's the same across things like poverty. I will go and talk to social justice committee and quite often it's centred around what can government do, the role of social security but actually with an issue like poverty you need to be asking what employers can do in terms of far work and petty. Exactly the same applies right across all areas of public policy. I think we need to stop viewing things in a very siloed nature that this is not just a health problem, this is a problem. The supermarkets, the employers, the housing associations, the landlords, et cetera, et cetera all have a role to play because again we know that the consequences of poverty are ill health and there was health inequalities that we continue to see. That's not something that health service can solve, it's something that health service can only deal with the consequences of until we start shifting the balance of the care that we're providing, where we're providing it and also then those wider public services. OK, thank you, thank you, convener. And Sandish Gohani. Professor, very briefly, can I ask, sorry, before I do that, my declaration of interest is a practicing NHS GP. Professor, very briefly, can I ask just to clarify what you said to Paul Sweeney earlier about the increase in staff pay. That increase in staff pay is going to lead to a cut in other aspects of NHS spend in Scotland. Sorry, I didn't quite catch your question. Sorry? I didn't quite catch your question. So, from what you've said to Paul Sweeney earlier, to clarify, the increase in staff pay in Scotland is going to lead to a cut in NHS budgets and NHS spend elsewhere. Is that what you said? No, it's not what I said. I said something slightly different, which was that in healthcare a lot of the progress we make through new technological developments tends to come in the form of better treatments for patients, ways to treat conditions that weren't previously treatable. It doesn't come in so much in the form of labour saving progress, where you're reducing the number of workers you need in order to deliver a given level of health. In some areas, that's the case. I gave the example of keyhole surgery where if you use keyhole surgery, there's less time involved in keeping the patients in hospital and less resource. So my point was more that you have to keep on recruiting staff who are out from other areas of work and they're going to benefit from the increases in wages that they get through technical progress. So you have to match those wage increases outside the health centre in order to carry on a tragic start, but you're not getting the corresponding reductions in the number of staff you need to treat patients. So that's driving up your cost of treating patients. That was the point I was trying to make. Thank you. Philip, you said twice that staffing is our biggest resource and our biggest cost, which is obviously true, but I don't know if you're able to answer it or Professor David, you're able to answer this, but what's our spend on NHS managers? I don't have that figure to hand. I started to look at, so that 12.9% is obviously the overall NHS workforce, which includes administrative staff, managerial staff, et cetera. I had to start to break the number of staff so I had them to hand yesterday and didn't get a chance to, so I'm not too sure on what spend or proportion of staffing is in that. Yeah, I think there's a point that I absolutely kind of get when you're coming from the front line staff that was delivering card and was important. Obviously you need to make sure there are hospitals, everything else are well run. That does require managerial staff, so I certainly wouldn't make any judgments about whether or not the balance there is too high or not. But I don't have those figures to hand. Seeing as you were working on it, could you send them through if that would be okay? Thank you. I'm actually going to come back to Sandish Gohani to move on to our next theme. Thank you. Again, sorry, coming back to you, Philip. In response to Tess White, you spoke about preventative medicine and as a GP, obviously I'm going to come on to talk about this. I think that we must transform the way we think about and deliver healthcare. We can't keep focusing on health with what we do now. We can't treat the NHS like a bike repair shop where people just come in and get repaired. We need to get them better beforehand. Organisations like the British Society of Lifestyle Medicine are advocating for this preventative agenda. I know you spoke about it earlier, but I'd just like you to expand. Could you give us some tangible examples of where we could implement preventative spend, where the things that we could do within healthcare budgets to achieve this? There are probably health-led measures that need to exist outwith the health service. You look at standards in housing. Again, we know that the housing stock is most likely to be substandards for people living in poverty in more deprived areas. We know again that low standards in housing can give rise to things like respiratory diseases. I'm sure you've probably seen it being presented in surgeries and everything else. It's the non-health service bit to the gain. I don't think we've tackled yet. We often talk about this as an issue of poverty, so we'll try to address it as an issue of poverty, but we quite often still don't make those connections with us. It's not until health inequality starts to come out every year that we go, that there's a big link between health inequalities and deprivation. We don't think to address those things as a health issue. We continue to address them as a social issue. We've been able to do those things with the health service. If you look within the health system, again, there has been good innovations over the last couple of years, so the multidisciplinary teams that have been formed. There's evidence to suggest that the outcomes still haven't been fantastic, but I think at least it's an anecdotal. If not in delivering better health outcomes yet and being able to bring those professionals together and be able to start to coordinate the advice and the services that they're providing, it's really important, not least in particular with the inclusion of mental health, because again we know there's been a huge rise in mental health over the last few years and again it's got huge corresponding impacts on things like dissipation of the labour market and everything else. So those have shown a good example of where you can start to bring resources together within communities. That potentially then gives rise to the development of more hub and spoke type models, where you've got a really strong central hub within a community, but ensuring that then actually what your GP services have become is about being able to provide continuity of care. So again, I think if you look at experience surveys, if you look at obviously the implication of kind of resourcing over the last few years, and again you might have personal experience of this, what we know is that one thing that potentially starts to, one of the first things that can give within primary care and particularly within GP practices is that continuity of care, and that the same GP isn't able to provide care to the same patient every single time, because resources are so stretched. So that hub and spoke model potentially then gives rise to being able to allow GP's to focus on that much more and you've got a much stronger centre. You look at things like community link workers. I think if you talk to any kind of any health professional that is a part of those, but in particular those deep end GP practices that obviously have been in the forefront of their development, they have had a hugely beneficial role again in providing that kind of more social prescribing, not on health support, which again we know quite often GP's can become burdens, burdens are not the right word to use, but people are often presenting with those not on health issues. Again community link workers presents a brilliant resource there, but obviously again we've seen reports over the last few months of the risk to staffing numbers among CLWs in particular in those local authorities where they're needed most like Glasgow. So I think those are the sorts of things that I think we should be looking at doing more, there's probably further renovations that again go beyond my area of expertise. But I think what it all comes down to is having that, whether you call it a multidisciplinary team, whether you call it hub and spoke, whatever you call it, ensuring that we start to bring those wider resources much closer to communities that can play that role in tackling the causes. I mean it would prevent them much earlier whilst ensuring that we free up GP's, we ought to provide that continuing care and we ought to provide that kind of friendly face and such a cliched way to put it, but being able to do that to ensure that kind of everyone has access to that continuity of care is really important. I couldn't agree more with what you said about GP's, it's really important that when I'm doing my job as a GP I want to be sure that I'm helping people's health and not trying to focus on their social issues because there are other people who are probably better placed to do that. You brought up community link workers and in Glasgow we're going to see deep cuts made to community link workers and I've received a lot of correspondence from community link workers, I've gone and spoken to deep end practices, I've spoken to GP's, I've stopped in the streets talking about this because the good that they do is huge. But the worry that a lot of my community link workers that have responded are saying to me that if they're cut they're going to have to go from one practice to three practices, they'll have a day a week maybe in each practice and that will significantly hinder the work that they will be able to do to the community. So what value should we be placing on these community link workers especially in our most deprived areas? So again I'm very conscious I don't want to dominate proceedings here, I was hoping to have someone else to give it at some point. I think it comes back to that point that I don't think we would have the same debate about or the same risk to community link workers that we would have around staffing in any other part of the system because again what we continue to do is prioritise and again I understand it and this is not to say that anything about it but we continue to kind of, attention and focus goes on the secondary system. And primary care and community lead care continues to kind of very much be a distant runner up in that debate. We need to absolutely start recognising the importance of things like link workers again, things like multidisciplinary teams, actually deep end practices themselves, being able to kind of celebrate the role that they play much more. And I just don't think we're there yet because I still don't think we've cracked that kind of nut of the recognition of the important role that we place on community lead care and being able to ensure that not that it starts to dominate over secondary care but we start to recognise that actually the health system is at least three or four different bits and each of them needs to be as well resourced and kind of as respected and as part of the solution as any other. But I don't think we're there yet because I think again it comes back to that. We still quite often do not see social issues as health issues and vice versa or at least not to the extent to which we should. I'm aware that other people want to come into this and my last question and I'm sorry I'm sticking with you here because about 80 to 90% of all patient contacts happens in primary care. That's where people access health care and you're right when you say we're not quite there when it comes to the resourcing. It is dominated by secondary care and we've seen a 65 million pound cut in the primary care budget last year. So with that happening how are we expecting our GPs to provide a service that does enable this preventative agenda. How can we get our GPs to have the time to ask about things like alcohol or cigarettes or other questions as opposed to the only thing that comes through the door. Do you have any ways that we could maybe do that? Firstly on the funding points I think so there's been lots of attention placed to the overall commitment to increase the overall health budget by 20% which was originally by the end of this parliament and obviously has been met already. I'd potentially a question there of whether or not that was was that a commitment that was made because they were confident of being met or actually wasn't a much needed increase this early in the parliament. I'd say these to go much further than 20% but I think what also gets forgotten is that in its first programme for government of this parliament Scottish government also committed to increasing primary spend by 25% over this parliament and then at least half of all front line spend going into community health. The opacity of primary funding, community health funding means that I'm not sure whether or not that commitment is being met or what that looks like or what success looks like. So I think that's part of the problem as well is that quite often we don't know where the money is going in primary care because it's not as simple of here is a health board and I'm going to give you your budget. I think it's just a point on funding that there are equally big funding commitments for primary care but I'm not sure of the extent to which they're being met in the same way that kind of the overall health budget is. The secondary point is a question of whose role is it and I would imagine that you would say that it's not a GP's role to be providing those kinds of services and I think that's where we need to start thinking about alternative delivery models. Ensuring that we can free up GPs to be able to provide that continuing care to be able to ensure that they are able to see the same patients, know what their history is, know what their needs are and then having that wider support network within surgeries. Again, we've got things like the commitment to ensure that every GP practice has a mental health worker by the end of this Parliament. Those are really important commitments and we need to ensure that they're being met because ensuring that people within communities know where they can go for that source of advice. We've got no wrong door approaches, we've got holistic services being provided in one place so people don't have to go all over the place to be able to find that support is incredibly important. I don't even know if it's about who is providing it, what is probably the most important thing is where it's being provided and the assurance that if you go and seek it you will be able to access it. Excuse me, I'm going to move on to another MSP. Gillian Mackay joins us remotely. Thanks, convener, and good morning to the panel. If I could come back to Philip White on something that we picked up with Emma Harper earlier on about preventing people from falling into poverty and having enough money to live on in the first place. With that in mind, what impact does the panel believe the introduction of a universal basic income or a minimum income guarantee could have on the health and social care system in terms of reducing strain and costs? OK, let me just say again, our remit in the fiscal commissions, we cannot comment on new policies, we can only comment on policies that have been produced by the Scottish Government but just to maybe make my point that I was about to make, there is an important interaction between spending on health and spending on other areas of government. This is about to your vice versa point, so we do observe that because of the increase in waiting lists in the NHS, that is showing up in spending on social security, particularly disability benefits. And now 40% of disability benefits arise because of mental health issues. So the more you can get better delivery of healthcare that has important implications for spending on social security, and also there is some evidence now that it might increase participation rates in the economy. So you get more people working, you get higher levels of GDP, higher levels of income, a point that Carmen was making earlier on, and so tax revenue could potentially go up. So I think it's really important that we see the overlap between health, what's going on in health, what's going on in social security, what's going on in tax, and we take that more ballistic picture of what's happening in government, which goes back to the point about the important interactions between these things. I'm sorry I didn't quite answer your question, Julianne. I think I'll try to contribute. So regarding the minimum income guarantee, we know that socio-economic factors have implications for health inequalities. I think we've seen that with austerity for the last 10, 13 years, and there is a wealth of evidence that links austerity with health inequalities. And from the survey that we've run at the beginning of the year and other surveys that we've run with civil society organisations, we've seen that, for example, in the case of women, they are already using different strategies to be able to face or to navigate the cost of living crisis. So again, the cost of living crisis will have an impact on poverty, and this will have an impact on future spending and pressures on the NHS as well. So key finders, for example, 70% of the women that responded to our survey and the total was 871, said that they have not been putting heating on to reduce costs, and almost 20% of respondents are skipping meals entirely. These increases to almost 34% for disabled women and 46% for single parents. Regarding care costs, some women have also said to us that they have struggled to meet these or to afford them. We also know that provision hasn't got back to what it was prior to the pandemic. We also know that some women are struggling to attend health appointments due to the cost of transport. So again, the minimum income guarantee, as long as it's well thought out and it provides the minimum, could help to at least absorb some of the consequences that the current economic situation is having on people and on women particularly. That's great. Thank you. I'm now going to move on to Paul Sweeney. Thanks, convener, and thank you to the panel for their further contribution. The committee recently invited views on winter planning in the national health service, and many submissions suggest that the development of a whole systems approach is hindered by the short term nature planning and funding. Do any of the panel members have a view on how we can achieve a whole systems approach in any practical sense? It's not something that we've covered. The IPPR's recent report on social and economic harm of poverty in Scotland has highlighted the reactive spending cycle as an avoidable one. Do you have a view on how we disrupt that cycle and transition to an increase in preventative spending against the backdrop of such acute pressures on secondary services? I think I've quite covered lots of this in response to Emma's question earlier. It is a delicate balance. I think actually David's highlighted a really big problem here as well, which is that I can sit here and say we need to shift the balance of spend, but actually we also need to ensure that we're still spending and tackling the elective backlog, because we know that the longer people spend on a waiting list, the poorer that their health becomes, and the greater likelihood is that they exit the labour market. If they were in it to start with, and we've already seen a rise in chronic and long-term conditions, which again has resulted in us getting poorer. So it is an incredibly difficult kind of seesaw to start to try and balance. I think as I go back to some of the responses earlier, there is an issue of looking within the health service, so ensuring that we're getting that balance between the resource that we're putting into primary and the resource that we're putting into secondary care, right? Because again primary care will often treat the causes, whereas secondary care will treat the consequences, and then secondly ensuring that in our wider social policy spending, so again things like housing, things like social security, that we're recognising responding to as much as a health issue as it is an issue of poverty, because health inequality is in particular or a matter of poverty, and vice versa. So our point doesn't really matter which way you approach it from, do you approach it as a health issue or an issue of poverty, but I think just starting to recognise that the two are intertwined, and we start to tackle them as such. Do you have any examples of either instances of service provision within Scotland or in other countries where that transition has been managed and showed promising signs? We looked at some as part of UK-wide research, so I don't have it immediately to hands, because it was UK-wide rather than from IPR Scotland specifically, but certainly happy. We looked at a couple of different models for primary care and where that prevented a shift to taking place, so happy to provide a follow-up submission. Thanks, it's just kind on the back of other questions that have been asked already. In the IPPR report, Philip, it's tipping the scales of social and economic harms of poverty. It says in section 2 that important action has been taken within devolved powers, demonstrating what can be achieved with political will and investment, particularly following the devolution of new welfare powers and establishment of Social Security Scotland. There's like 12 new benefits, which are more than £1 billion, council tax reduction, Scottish child payment, best start grant. A lot of those are outside the health portfolio, and we know that ministers in the Scottish Government, housing minister, health minister, mental health, they've all got their own portfolios, but everything crosses over if we're looking at health and health improvement. I'm interested in, I suppose, the way that we look at the budget, how do we then, I suppose, we need to value what has been set up with Social Security Scotland, fairness, dignity and respect, rather than a punitive approach, which the Department of Work and Pensions has. So I'm interested in if you think there's anything else that should be picked up in the form of like support or welfare support to help to improve this safety net that we have in Scotland. I would like to say something about Social Security spending, because it's a very important area. The policies that you talk about, Scottish child payment, the reforms that have been made to the way in which particularly disability benefits are delivered, those all have spending consequences, and because of the way in which the Scottish budget operates, those are not covered by any block grant adjustment coming from the UK Government, so those fall entirely on the Scottish budget. So that means that in 2728 there will be about £1.2 billion of spending on Social Security, which is not funded by block grant adjustment from the rest of the UK. About half of that arises because of spending on Scottish only policies like child payment, but half of it comes from the consequences of the way in which we deliver disability benefits, so roughly half and half. By the end of the 50-year period, we project that gross to £3.2 billion, and now a large chunk of that, but £2.2 billion comes from the reforms that have been made to the way in which Social Security is delivered, particularly through disability benefits, and about £1 billion comes from payments like Scottish child payment. So while all of these reforms have very good intentions, they do have physical consequences that fall entirely on the Scottish budget and are not coming through any block grant adjustment from the UK Government. So it's just important to be aware of those costs that fall on the Scottish budget when you make these reforms. In the recent information that I read, it was like the Scottish Government is mitigating £700 million in support for things like bedroom tax, for instance, things like that. I know I'm straying into politics a bit, but the Barnett formula makes adjustments for us in Scotland. We're constrained by the way that the budget is delivered in Scotland by another Government. Is that something that we maybe need to be looking at alternatives to how the Scottish Government's block grant is delivered? Well, there's two elements of the block grant. One is the block grant, the Barnett consequentials, which flow through the things like health, and the other are block grant adjustments, which come in two areas. One is on income tax. So what you try to do there is the Office of Budget Responsibility will try to forecast what tax revenues Scotland would have raised had it remained part of the UK tax system. So Scotland gets tax revenue that it raises, but then you subtract from that what the OBR estimates it would have raised had it remained part of the UK tax system. So had the Scottish economy and earnings grown the same way as the UK, had the tax rates been the same as in the rest of the UK. So that's the block grant adjustment relating to income tax. There's a similar block grant adjustment relating to social security, where essentially you're asking the question, what would have been spent in Scotland, has Scotland remained part of the UK social security system, and that block grant is given to Scotland, but then if Scotland makes decisions, which means it spends more than that, then that increase falls entirely on the Scottish budget. So it is things like having different policies from the UK, like Scottish child payment, that falls entirely on the Scottish budget, and it is the consequence of the reforms you make to the way in which social security is delivered that has consequences that fall on the Scottish budget. Now that there has been a review of the fiscal framework in Scotland, that is a place where some of these questions were being addressed as to how the fiscal framework operates, but under the existing fiscal framework, these are the implications of decisions that are being made by the Scottish Government and, of course, the Parliament. The biggest commodity in the national services is time. There are, of course, opportunities to boost productivity through capital investments and to tackle inefficiencies through targeted process improvements, but GPs, for example, say that they are understandably too busy firefighting to undertake any sort of innovation or process improvement. Do panel members have examples from other countries of models of innovation, which has improved demonstrably productivity and helped to deliver on positive health and social care outcomes? Written submissions to the committee have noted that the short-term nature of national targets are impacting clinical priorities with decisions made to satisfy expectations as opposed to measuring long-term impact. Do panel members have a view on alternative measures, perhaps through budgeting, that could be used to monitor performance that allows for longer-term planning? How do we shift from that short-termism to a longer-term funding and service delivery model bearing in mind the complex interactions between Treasury and the Scottish Government? One of the reasons we published our fiscal sustainability report back in March this year is that the first one that we have done was precisely to try to get people to understand the longer-term trends that are happening on both spending and on funding and resources. By understanding that longer-term trend, you can then start to think about making different decisions about how you want to prioritise spending. That was exactly the motive for doing this. It just provides more information and more background that helps you to understand the consequences of pursuing existing policies over a longer period of time. As the convener reported earlier, the Scottish Government has already responded to our report by increasing the amount of spending to spend on health by 4 per cent rather than 3.5 per cent. That is exactly the kind of impact we are thinking that type of long-term framework or thinking will have. It will just help MPs, Parliament and Government to understand the long-term implications of existing policies for both funding and spending. First, on budgeting, I used to work in Government, so I know what difficult process is setting budgets. You go back to, for example, the resource spending review last year. We ended up with level 2 figures, which are better than what we previously had in terms of understanding of long-term budget outcomes or potentials. Level 2 does not provide you with any kind of detail to know. If you take health and social care, we have a health and social care level 2 budget. I get that there is huge uncertainty around funding over this Parliament, which we saw last year, for example, with the many budget, where funding went up and then down within a matter of a few weeks. It is really difficult, but you need to at least attempt to do it. If you do a level 2 figure, one of two things has either happened. You either know your level 3 assumptions beneath that, but you have chosen not to publish them, which is potentially valid reasons for that. Or you do not know your level 3 figures, and you have a level 2 figure that is not informed by where you are going to put that money. It needs to be some attempt to move to a level beneath that whenever it comes to that long-term budget setting. Second, on targets, I think I would go back to what I said before. I do not think targets are inherently wrong, albeit I know that health boards have a huge amount of targets now that they are expected to adhere to or meet. I think I would go back to if you take the elective backlog, for example, that was a national-level top-down target, or at least ambition, that government set in its NHS recovery plan. It is good to set that, but I think a lot of Scotland has flagged that it is unclear the modelling that went into arriving at that national target. It is a national-level figure, but secondly, as I said, we know the capacity that waiting lists everything else, specialties, all very hugely by health board. So, actually, again, what bearing does that have? What contribution are you expecting each health board to make to that national-level outcome? You do not know unless you have done it from a bottom-up approach. That is just the two things I would say. On funding, we need to try and drill down a level, and on targets, it is right to set them, but you need to ensure that it is for and from a bottom-up approach. Can you elaborate maybe on the evidence base for a longer-term objective setting and setting those budgets accordingly? Interesting examples might be health and social care partnerships, cutting a programme without any reference back to the centre and what it might be having on national performance. Do you think that we need to be doing more to improve those metrics and KPIs? I am not sure if we have. At the minute, when it comes to outcomes-based budgeting, we are not there yet. Again, you take the commitment at the start of this Parliament to increase the health budget by 20 per cent by the end of the Parliament. That has been met already. I am not sure where that 20 per cent increase came from. It is not a bad thing, obviously. It is good, but why 20 per cent? I do not know why it was 20 per cent and not 25 per cent, why it was not 15 per cent. It has been met already, so do we need to increase it now to the end of this Parliament? In meeting it halfway through the Parliament, it means that we have underestimated the increase required. Are you interested in a national level, targets like that or commitments like that, ensuring that trying to have a better understanding of the evidence base that has informed them and actually why you want to increase the budget? What is that increase being spent on? The same thing happens if you take it down a level. I do not think that, obviously, in lots of committee discussions we will talk about things like the NPF. The NPF is described within government as North Star. I always really torture this cliché, so I apologise in advance. North stars are good. If I get lost I can follow the North Star and have a good idea of where I am going, but it still does not mean that I do not run the risk of falling off a cliff unless I actually know what my route is. It is fine to have that big, national level macro North Star to follow, but you need to know what your route map is. I do not think that we have that lower level, whatever you want to term them, outside of targets that have had been set nationally. I am not sure if we know where we are going yet. That is helpful. Just on the back of the budgets and data, the Scottish Women's Budget Group would support a review into the integration of health and social care and how this is working particularly in relation to shared budgets and the impact that decisions being taken in relation to social care influence health and social and other services. So, for example, East Lothian Council clearly stated in their budget papers for this year that the increased funding they got for wages would not be passed on to the integration joint board. In addition, Glasgow integration joint board has had to make 21 million of cuts to its budget, with budget papers recognising that this will increase the waiting list for those who need to care packages, reduce the care services and care home beds, and may lead to failure to meet statutory duties. That suggests that there is a continuation of looking at things in silos, which means that the consequences of the issues do not consider the bigger picture in the long term as well. In our call for views, a number of respondents said that there was a need for public engagement in relation to health and social care spending and the choices that need to be made. Do you think that this is a good idea generally? And also, how can it be done well to make sure that we do not increase people's expectations maybe in the wrong way? And to anyone that would like to come in? I'm really sorry, but we don't comment on all the kinds of issues. We think that there probably needs to be a conversation as to what people expect from health and from care, and probably taxation needs to be included as part of that conversation. And following on from previous questions, there might be a conversation as well as to how we empower people as well to think about their health and what choices can be made, for example, talking about foods earlier. As to how you do it, we don't really have a view because we haven't engaged with that, but we are happy to discuss with our members and get back to you. So it's a good thing. One of the things that I often come back to is that I often think about how do you fix it? It comes back to the shift of where you deliver care, the redesign of version care that we went through over the last few years. You could argue whether or not there was a very grand title for what the reforms actually were, but if you take just one, for example, the advice to not present an A&E and actually hear the number that you can ring and they will tree as you, and then you could then determine whether or not you need to present an A&E to try and would just say any numbers down for obvious reasons, but again, actually recognising that quite often you don't need to go into a secondary setting that there will be other avenues of support. So that is, if you want to talk about shifting the balance of care, that is absolutely the appropriate kind of thing to do and that was the right thing to do, but it was uproar. People thought they were being told, because there's this expectation that, or not an expectation, but obviously the way we talk about the health service that is a national service and it's a right and it's an entitlement. So there's uproar that people are being told not to go to the A&E, that obviously political attention pay to public weren't too sure what to do. So you could argue that kind of the way that was gone about and communicated to many people were engaged with was wrong, but I think it just highlights a kind of tension that we sometimes have in this that people want more GPs, people want to be able to see their GP, but at the same time actually obviously want to be able to go to A&E any time of day, we know with whatever ailment they have. But I think that's part of the problem that we need to be able to actually have that growing up discussion of what is the health system for, what are the individual bits of the health system for, how do you access them and actually is the way it's set up right now, appropriate, because if you take something like that change to advice around presenting at A&E, the way it was viewed and the way it was perceived, certainly I don't think bore any relation to actually what the reform was trying to do and there's potentially fault in all side for that, but I think it provides you really useful microcosm of actually I don't think we're yet able to have that kind of grown up debate about alternative models of care, because even something like that caused untold amounts of anguish and upset. So to come back on some of those points, so generally it's felt to be a good idea, there should be an open and transparent conversation with the public about health and social care and how we move forward with it, but from the comment you're making it's maybe not going to be that easy, it's going to have to be very well thought out. I think the NHS is absolutely the dual crown of public services and that applies right across the UK, that means that people have a huge emotional attachment to it, as none of you will be strangers to it, it is often the very largest political football that gets battered around, that's, footballs don't get battered around so that was a bad metaphor to use, but so on both sides there is huge public attachment and on the other side there is huge public pressure, attention, everything, so on both sides something has to give there, I think, and that is incredibly difficult, it's very easy for me to sit here and say because I have got no solutions for how you do that, but something has to give that we're able to kind of start thinking about how the system is set up and designed and delivered, because we don't, we're going to persist with this model that is chewing up resources in secondary and still not delivering the current communities that people need in primary. I was just going to make a comment, I think that the comments that you've made have been very good and I would agree that these conversations sometimes are difficult because the public are thinking about things in a different way, but I think in some of the communications that I saw going out from the Government about say social prescribing, multi disciplinary teams, it made people start talking about it, it made people start having a conversation with each other about how we do things better, so I think we've got to do it even if it's difficult. Emma Harper. Thank you, convener, I will be quick. I'm thinking about community pharmacy as another way to direct people, so pharmacy first for instance, and then there's also our national treatment centres that have been established so that elective surgery can be done so that emergency beds are not taking up the space for elective patients, so that's something that has been done. I feel like we're spinning plates sometimes and none of this is an overnight fix. Like I used the example of Professor Pekka Puska in Finland, it was three decades for him to reduce the mortality of the men from cardiovascular disease by 80 per cent, but they made that approach. I suppose my question is that is the Scottish Government going in the right direction when it comes to budget choices and health choices and on the back of Evelyn's question making helping people manage expectations as well? I think the Scottish Government has, they do know what the issues are and I think they have kind of taken some good steps, but maybe the issues also come when it comes to implementation, for example, or to evaluation of some of the initiatives. I'm thinking just now about the women's health plan, so this was approved I think a year or two years ago and it was meant to be funded with COVID and team recovery funds. However, we have submitted some freedom of information requests to some boards and two have come back to us. Lodion, for example, saying that no specific central funding attached to the women's health plan has been allocated to delivering the priorities, aims and actions in Lodion and Highland has come back to us saying that they are still trying to assert if they have information to provide a response to our request. So, from this example, we could say that yes, they have taken some steps and they have identified a need to decrease health inequalities and to look at women's health. However, because there is no budget attached to it, we don't know how successful that plan will be. I suppose that, in conclusion, there is more that could be done. Is that like an NHS board's responsibility to deliver what the Government has a plan but the NHS board would be the one delivering the women's health plan, for instance, in the NHS Lodion area? Measuring that is something that NHS Lodion would propose that they would monitor how their plan has been delivered and what outcomes they have achieved. Yes, I suppose, but because the plan comes from the Scottish Government, I suppose there will be some sort of way to measure this or to follow up. Thank you, and we'll move on to our final theme, and Tandish Gohani. Thank you. This is a question for Sir David, but Philip, you started by saying that there was an opacity into seeing the spending in primary care. My question, Professor, is data sufficiently transparent regarding specific Scottish Government commitments such as mental health commitments regarding the budget so that we can effectively monitor it? I keep on apologising to you because, as I say, we do not forecast spending on health, so we don't go down to the level of detail to know what is available in the way of data in order to reduce forecast for health spending. I'm just not able to comment on the adequacy of the data here. We just don't forecast health. The projections we did for the physical sustainability report, we did draw on some data about the breakdown into spending in primary, secondary healthcare. So we had some kind of data in order to make our projections, but these are pretty rough and ready figures we used, and we were just doing long-term projections starting from that starting point. When we do our budget forecasts on income taxes and on social security, we have much, much more detailed data which we use to feed into our forecasts, and we spend a lot of time working with both HMRC and with Social Security Scotland to make sure we have the data to do our forecasts. Every year, we publish a statement of data needs of where we still think there are gaps in the data that we need in order to do our forecasts better and improve the accuracy of our forecasts, but because we don't forecast health spending, we've never ever published a statement of data needs in relationship to health data. My same question is to Carmen. I think social care is often seen as a Cinderella service whose sole job it is is to prop up the NHS, allow speedy discharges, allow hospitals to work more efficiently, but it needs to be seen as a vital part of care that we have. So when it comes to looking at how social care and the social care data is used to see what we can do, how we can make improvements, do you think we have adequate data when it comes to social care and if not, what do you think is missing? I don't think I'm going to be able to give you the detail as to what is missing right now, but I can get back to you after this, but there is definitely some data missing because when we issued our reports, we had to base some estimations on data from England. So that is definitely a gap. Going back to your previous question about data, what is missing or not, the audience of Scotland published this month a report on mental health and how it has made remarks about the complexity of the current system and how it makes it more difficult to develop and provide special centre services. So there are multiple organisations involved in the planning and funding and provided adult mental health services, including the integration joint boards, health and social care professionals, NHS councils and third sector organisations. So again, sometimes trying to get data from these is quite complicated and there was a recommendation going back to the point that I made earlier about how the Scottish Government should work with NHS boards and the integration joint boards to improve accountability arrangements. So, and again, in terms of data and budgets, we know that most of the, you know, there is these integrations about health and care, but most of the budget usually goes to health. So there is, again, like for social care, we still, we would say that it is still underfunded and undervalued and that this needs to be tackled and improved. So we could get greater outcomes and we could also improve prevention. It must be part of the system and be at the centre. Thank you. And my last question is to you, Philip. So for me, as a taxpayer, when money is spent, I think it's important we know where that money is spent and there's an audit trail with that spending of money. Is that too simplistic of you when it comes to health to seeing where our money is being spent and how? So I don't think it would be simplistic. There is an issue about, I think in particular, again, if you look at secondary, once it hits a health boards budget, it's very difficult to know what then sits beneath each individual health boards budget. That data is really difficult to find, and quite often you have to do it after the fact whenever audit accounts are produced. So, you know, there is a bit of a thing of, you know, once it's left Scottish Government budget into health boards, it should then equally be split out at a level beneath that. I think does that tell you, it might tell you where it's being spent. I'm not sure it tells you what outcomes it's having. I definitely don't think it will tell you if it's being spent in the right way. You know, I've done this for a long time and I still couldn't tell you really. I wouldn't know where to start shifting money around. So I think data is an issue. There is issues, you know, issues around funding. So again, you take one commitment from government, a really good one, that 10% of all health line or frontline health spend will go on mental health by the end of this parliament. But again, that because that's delivered through health boards, because then it's up to health boards to determine how much money they're putting where, you've got absolutely no idea if that's being delivered. And more importantly, who's doing the heavy lifting of delivering that commitment. So things like that become impossible to track. So it's an issue of that, just transparency of where money is going. I think the more important thing is data. So data exists across multiple different sources. It's incredibly difficult to find, even if you do find it, quite often it's not made user friendly. Like, yeah, I don't think on both transparency and data, I think every committee actually is probably doing his pre-budget scrutiny and beyond is probably having a very similar discussion because it's not unique to health. But I think because quite often the health is such a complex area, it becomes kind of even more heightened. So it does. But yeah, the ultimate point is that, you know, we've got good data around, you know, outcomes around diseases, et cetera, et cetera. But being able to find that and actually genuinely understanding what's driving it and more importantly how you can start to shift it becomes much more difficult. Thank you. I think it's important to understand the distinction between social security spending and other forms of spending. One feature of social security spending is essentially demand-led spending. So once the Scottish Government has set the eligibility criteria, has set the rates of pay that it will pay for in certain conditions, has set all the way in which the benefits will be delivered, the information it requires from people applying for benefits, et cetera. Once it's set all of that, the level of spending is essentially determined by the number of people who turn up and claim those benefits. You don't get to choose the amount of spending that is determined by the people who claim the benefits. So it's not like there's a big... I wasn't talking about benefits. Sorry? I wasn't talking about benefits. I understand that. My point is that you don't get to choose certain elements of overall budgeting. So you don't get to choose the amount that's spent on social security. Basically what you get to choose is how you spend the rest between health, education and other resources. The spending on social security, you determine the conditions and the way people can apply. But the amount that's ultimately spent is determined by who turns up and claims that. That's why when we produce our fiscal reports, what we do is we produce the overall budget. We subtract off social security spending and then we say there's the budget that's left to spend on everything else. So if you're going to have a discussion about it, are we having the right information? Are we making the right decisions about it? Are we spending on these seven areas? One area is spend that you don't have the same degree of control over in social security. Thank you. I just wanted to pick up on some of the modelling that's been done in the productivity paper that you've prepared. If you take the National Health Service workforce in Scotland, it's the fourth largest city in Scotland. I think the headcount sits at 181,000 people. So the biggest employer in Scotland by a considerable distance. That clearly has an effect on national performance in terms of productivity. Do you have any thoughts on whether we can improve our analysis of the productivity of the National Health Service as a workforce and actually informing national policy? Most of the work that we've done on productivity is on productivity across the economy as a whole. That feeds into what's happening in the health service but we haven't done a specific study of productivity in the health service. We've looked at the consequences for the health service of productivity that's taking place in the rest of the economy. We've just published a paper where we show how different assumptions about productivity have different impacts on the overall sustainability for the Scottish economy. We might come back to you to ask further information about the potential of doing deeper analysis on the National Health Service and its productivity. That might be something of interest to the committee. So thanks for that insight. Thank you very much. Emma Harper, do you have a very brief? I need to remind everybody that I'm a current registered nurse. I forgot to say that at the beginning. It's a quick question about economy. Normally we measure gross domestic product as a measure of how successful a country is. We now have a wellbeing economy, Cabinet Secretary, so we're looking at wellbeing. We know that if we help to get people out of poverty then that supports them into being more productive. Do you agree that supporting a wellbeing economy approach is a way that we can look at how we budget for health because it will address, right across the portfolios when we're talking about housing, poverty and addressing the issues that we face in Scotland? The simplest answer might be whether to get into it today, but in the follow-up note we've done a lot of research at the UK level showing exactly that of one of the consequences from an economic perspective of the decline in health. Then vice-versa, if we were to get a healthier population, what does that do for the economy? So I can maybe provide some of that in a note, but I don't know if, Carmen, you think I wouldn't say anything. Have anything to say about the wellbeing economy just now? I'm asking because I'm the co-convener of the wellbeing economy cross-party group and we've had lots of interesting discussion around how it's good to support wellbeing as a nation and not just measure productivity on GDP. I think it is important to have a healthy nation and by improving health outcomes you might have also more people that are able to enter the labour market. Again, when we did this cost-of-care modelling report we were also thinking about job creation and making the care sector more competitive and more attractive. Also bearing in mind the number of unpaid carers in Scotland and how this could help to bring people into the labour market, especially in the context of a shrinking workforce as we know from the fiscal commission report. GDP as an absolute measure of how well the economy is running is just a measure but it doesn't take into consideration care, for example. We also know that it is good to have a growing economy but it doesn't translate always into greater outcomes or equality or equity. It's something that is there but a wellbeing economy measures success in a way that is more appropriate considering the policy commitments. I thank the witnesses for their evidence to committee this morning. The next item on agenda is consideration of one negative instrument, the personal injuries NHS charges amounts to Scotland amendment 2, regulations 2023. The purpose of the instrument is to increase the charges recovered from persons who pay compensation in cases where an injured person receives national health service hospital treatment or ambulance services. The increase in charges relates to an uplift for hospital and community health service HCHS inflation. The policy note states that the NHS charges are revised annually from 1 April to take account of hospital and community health services pay and price inflation. The last division took effect on 1 April 2023 applying the estimate for HCHS inflation at the time of 2.8 per cent. As a result of subsequent NHS pay deals and the latest estimate for HCHS inflation is 5.3 per cent and this mid-year tariff uplift addresses a significant gap between the forecast and actual pay inflation. The Delegated Powers and Law Reform Committee considered the instrument meeting on 12 September 2023 and made no recommendations in regard to the instrument. No motion to annul has been received in relation to the instrument. Do members have any comments? No, okay. I propose that the committee does not make any recommendations in relation to this negative instrument. Do members disagree with this? No, okay. Our next meeting of the committee will briefly consider a negative instrument. It will be followed by a joint meeting of selected members of the health, social care and sport, social justice and social security and criminal justice committees to scrutinise drug policy. Our meeting on 3 October will receive an update from the Minister for Social Care, Mental Well-being and Sport on the National Care Service, Scotland Bill and will continue your pre-budgets, Christiane, and that concludes the public part of your meeting today.