 Welcome, everyone, to the 17th meeting of the Health, Social Care and Sport Committee in 2022. I've received no apologies for today's meeting. The first item on our agenda is to decide whether to take item 3 in private. Our members agreed. We're agreed, thank you. Our second item today is an evidence session with the Cabinet Secretary for Health and Social Care on Audit Scotland's NHS in Scotland 2021 report. That follows never the session that the committee undertook with the Auditor General for Scotland on 19 April 2022. I'd like to welcome to the committee, Humza Yousaf, the Cabinet Secretary for Health and Social Care. He's joined by his officials, Richard McAllum, director of health, finance and governance, Gillian Russell, director of health, workforce and John Burns, the chief operating officer of NHS Scotland. Good morning to you all. I invite the cabinet secretary to make a brief opening statement. Good morning, convener. I hope that you and committee members are all safe and well. Good to be around the table, but all of us are present in person as well, so really good to see everybody. I'm really grateful for the committee for the time this morning. I can be relatively brief in my opening statement. I suspect most of the issues we will give a thorough exploration of those issues. I thank Audit Scotland first and foremost for the report into the NHS. It was informative. It was insightful. I think it was fair in terms of its recognition of the efforts that the Government has made, but also fair on where I think the Government and partners must go further in terms of our response particularly to the pandemic. The report correctly identifies that health and social care in Scotland is at a very critical juncture indeed. We're navigating our way out of the pandemic while dealing with case numbers that place continuing pressure on the NHS. It's not just current case numbers, it is the accumulative impact of the pandemic over the last two years, which continues to put pressure on our health services. In addition, we've seen the emergence of new challenges, such as long as Covid, which is having complex detrimental effects on people's lives. We'll be able to say more about that, of course, no doubt in this session, but also in the parliamentary debate taking place in this forthcoming parliamentary debate later this month. There are also challenges caused by the knock-on impacts of the pandemic. We know that we must address the backlog in treatment and care. We must support our workforce both in health and social care and ensure that everybody can access primary care in a way that supports them and addresses their clinical needs. Addressing those challenges will require significant change and changes to the way we deliver health and social care in Scotland while maintaining access to those vital services. As Audit Scotland reports, notes of our workforce has kept going in incredibly difficult circumstances. I want to thank, as I'm sure everybody else around this table would, our health and social care workers from across Scotland for the invaluable work that they have done, their tireless efforts throughout this pandemic. I recognise the monumental challenges that they have faced. Every single health and social care worker that I have spoken to has told me that the last couple of years have been the most difficult in their professional careers. That is why we have made £12 million available to support workforce wellbeing and put in place a national wellbeing helpline to support staff 24-7. When it comes to recruitment of staff, we are making significant progress. Members of the committee will be aware of our recent announcement where we have recruited almost 200 nurses internationally and many in the pipeline as well. That is in addition to the 1,000 additional support staff to work across the NHS and social care. More progress is needed. That is why we are taking the necessary steps to ensure that we recruit more staff but also, crucially, not just recruitment, what we can do to retain staff right across the NHS and social care. Order Scotland made clear that both healthcare and social care should be as inclusive and accessible as possible. Last year, we ran the general practice access campaign, which was shared across social media sites as well as across radio, for five weeks to reassure the public that general practices were open. That emphasises a variety of ways that treatment can be sought, including face-to-face, video and telephone consultations. Outside of general practice, we are continuing to develop a range of primary care services available, including NHS Pharmacy for Scotland and NHS 24, which I am delighted to have recently celebrated its 20th birthday. We are also developing more online resources through NHS Inform and indeed other challenges. The way in which we access services is changing and going to change, as are digital behaviours change and in accordance with clinical needs. By prioritising clinical resources, we are both managing demand and hopefully supporting people more effectively. Order Scotland, in the report, rightly identified the importance of gathering and sharing health data to help ensure transparency and the provision of effective joined up care right across the health and social care landscape. We have also committed to publishing a dedicated data strategy for health and social care that will be the first for Scotland and that we hope to publish that by autumn, excuse me, of this year. That is backed by the Scottish Government investing £112.9 million in digital health and care over 2022-23 to help to utilise and make the best use of digital technologies in the design but also in the delivery of our services. The NHS recovery plan, backed by over £1 billion of investment, set out our plans for health and care over the term of this Parliament. That includes over £400 million to create a network of national treatment centres across Scotland, increasing capacity for planned elective procedures but also diagnostic care. We are increasing NHS capacity by at least 10 per cent as quickly as possible to address the backlog of hair and meet on-going needs, healthcare needs across the country. To conclude, we are still dealing with the pandemic. It is not over yet. That pandemic continues to have profound effects on the health of our nation and on health services up and down the country. Our focus must be on ensuring that we transition out of this pandemic safely and in tackling the backlogs in immediate and essential care that has resulted. However, we must also provide access to care in a way that best suits people's needs. We need a strong workforce where wellbeing is protected, recruitment and retention is at extremely high levels. We need to adapt to ensure that new technologies and models of working can help support more of our citizens in their care as close to home as possible. That is my aim as Cabinet Secretary for Health and Social Care. I look forward to delving into those issues in more detail and of course happy to take your questions. My colleagues will be asking questions in quite a lot of the detail of what you have talked about. Not just the Audit Scotland report, but some of the Audit Scotland report really dovetails quite nicely into some of the things that we have had in previous inquiries that we have done, particularly around workforce. I imagine that quite a few of my colleagues might bring up some of the more specific stuff from our inquiries around alternative pathways, perinatal mental health. I want to ask you about the Care and Wellbeing portfolio and get a status report on where we are with that. One of the things that has been mentioned in the Audit Scotland report is about the sustainability of the NHS and social care, as it currently stands, or even before the pandemic, and how the Care and Wellbeing portfolio might improve that sustainability in the future, if you could, Cabinet Secretary. Thank you, convener. In terms of your first comment, I will take any questions that the committee wishes to ask. Where we can give you the detail today will give you the detail, of course. As always, I will provide you further in detail if that is required. As I mentioned in my opening remarks, I thought that the Audit Scotland report in the NHS was a fair one. I thought that it was a fair summary of the challenges. It highlighted the efforts that the Government has had to make in this extraordinary period. It will write about this period and learn about it in our schools, in our history books, in modern studies classes and so on, and so forth for a long past, since any of us will be around, I suspect. It was an extraordinary period. I want to again commend all those involved for their extraordinary efforts during that period. In terms of your specific question about the Care and Wellbeing portfolio, it would be fair to say that the work on the Care and Wellbeing portfolio has been affected by the pandemic. There is just no doubt about that. One of my lead officials, my key officials, joint director in relation to that portfolio, was working on the test and protect system for us. We had to move resources crucially away from various different parts of the Government to focus on the pandemic response. It is very much in developmental stage that officials are working to the defined intended scope. There are a number of work streams that I will touch upon in a second. We are very clear that the work on the Care and Wellbeing portfolio has to be broader than just healthcare, so how they interact with other departments and Governments is going to be crucial. The first meeting of the internal Care and Wellbeing portfolio board took place late last month, at the end of April. In terms of the sustainability question that you asked, it was absolutely on the money that question. The Care and Wellbeing portfolio, such a key element of that will be on the preventative side. We have talked in this committee and have spoken many times about the importance of that agenda. It is a crucial, vital part of our recovery and renewal of the NHS and social care moving forward. The Care and Wellbeing portfolio has got to be critical to that. That will help to make our services more sustainable. We can, of course, keep people out of going into our hospitals and acute sites. If they have to go there, keeping them there for as little or as short as possible, that is to their benefit, but it also helps to make our services more sustainable. One of the portfolio approaches is still being developed, but it has three primary objectives—coherence, sustainability and improved outcomes. That sustainability question that you asked is one of its key principal objectives, as well as prevention, care and wellbeing portfolio. We also have a big focus on innovation and developing the infrastructure that can really drive that efficiency and productivity within our health and care systems. I want to ask you one more thing about the expectations of the public around future healthcare and wellbeing. We are at a point now where we need to evaluate patient expectations about where they get their care, how they get their care, where they go, if they need care. The Scottish Government has put in a number of things in order to deal with the pathways that you mentioned at NHS 24, dial-in 111 instead of turning up at A&E etc. Do you think that we have still got a lot of work to do in terms of managing people's approach to their own healthcare and how they approach using the NHS? It is an excellent question. It is a question and an issue that I speak to regularly, particularly with the chief executives and the chairs of our health boards, who, if I am being honest, have a real anxiety about this question, because look for the rest of us around this table, life feels like it has got back to normal for most of us. We can interact with our family, we can book a holiday, we can hold a 70th birthday for our parents and have 100 people attend if we want. Life for most of us feels like it has got back to normal, but life in the health service is still under extraordinary pressure. I do not need to tell people around this table that they know it, because you are close to this. In one sense, people are asking, if my life has got back to normal, why does my health service not feel like it has got back to what it was like in pre-pandemic levels? There has got to be honesty, and I do this to the best of my ability, but there has got to be honesty right across the board to say that it is going to take not weeks, not months but years to recover our NHS. That is because there has been two years of accumulated challenge. I am not going to pretend that there was not a challenge in the health service before, but there was. Those issues are undoubtedly exacerbated, not just in the health service but in the care and social care in particular too, and those issues have just been exacerbated unbelievably so by the pandemic. It is important for us to be upfront, to be honest, to manage expectations but also to be ambitious. Our recovery plan is a demonstration of that ambition. The conversations that I have with my colleagues at the health board level across integration authorities when it comes to social care, we all want to be ambitious but also realistic as well. I do not speak about that very regularly, but there is a bit more work to be done around being able to cement our delivery milestones in relation to planned care in particular because we know how long people have been waiting for a number of elective procedures. A bit more work to do that, and of course we publish that in due course. That, I hope, will set a realistic timescale around recovery but also an ambitious one too. Your point is right that we have to be upfront and honest about the scale of the challenge and how people might well access their services. I am going to move on to talk about NHS reform in more detailed questions from Sue Webber. Thank you, cabinet secretary. I am living for coming along today. You have mentioned that we must change the way we deliver our health and social care while maintaining access. You have said also that you and Mr Burns are still discussing how the recovery plan will demonstrate that ambition for reform but there is still a lot to do in terms of setting milestones in concrete for your delivery plan. It has been eight months, as you have said, since the Scottish Government published the recovery plan. What is your assessment of the progress being made, if any, since its publication? We all understand and you have mentioned that there is no quick fix and we do understand that. The statistics coming out that we see daily are bleak on A and E cancer, delayed discharges and diagnosis. Is the plan working and what confidence can we have in that plan? I think that the question is a fair one about the recovery plan. What I would say to Ms Webber is that it is purposefully a five-year recovery plan. We will update Parliament, of course, as the plan says. We will come forward to Parliament with a yearly update so that update will happen when Parliament returns back from its summer recess. We plan to give that annual update in summer, so it will be a year on since the plan was published. What I would say—I think that Ms Webber, you would recognise this and I suspect everybody around the table would recognise this—is that we are not out of the pandemic yet. Not only are we not out of it, the most recent wave of the pandemic that we have dealt with has been the most challenging wave of the pandemic. Usually, if you take the alpha wave, the delta wave of the pandemic, the original variant of Covid, we knew that a wave would hit us and it would hit us really hard for two to three months and then we would be able to hopefully get out of the other side and try to recover. However, we have had wave after wave after wave in Omicron, which was seamlessly transitioned into BA2. We had Omicron wave that hit us around about December time seamlessly into BA2, which was the even more transmissible variant of a sublineage of Omicron. Of course, we have only just exited that wave most recently—a wave of about four to five months—during the height of the winter pressure. It was not at severity, because it was less severe than previous variants. It was transmissibility, which knocked out entire orthopedic words right across the country and hospitals up and down the country. There is no doubt that recovery has been hampered. In terms of the recovery plan itself, the foundations of that recovery plan are absolutely solid. The work that we are doing with CFSD, for example, to ensure that we drive innovation, the work on our NTCs—we hope that a number of NTCs and national treatment centres will come on board in the next 18 months. For example, the purchase of Caryglen, which will not come on board in those 18 months, will come on board as an important and crucial national treatment centre. On top of that, we can see where we have had just a bit of a lull in that pressure, the ability of the NHS to recover to some degree. For example, the last monthly statistics were published in relation to performed operations. We saw around about a 17 per cent increase of performed operations. There is the ability to recover, but I will not lie. It will be difficult and tough. The biggest threat to the recovery—the biggest threat, I think, by far—is our future variants of the virus. I think that our recovery plan will deliver. It is why I suspect that other nations of the UK that published similar recovery plans thereafter—the UK Government, the Welsh Government—were not too dissimilar to ours at all, because everybody recognises that this is not going to be fixed in a year. Thank you, cabinet secretary. You mentioned that the NHS is under pressure. We know that. I would also test if I state today that it is always under some form of pressure, and it has been in all the years that I worked in that environment before coming to Parliament. The Audit Scotland report notes that there is not enough detail in the five-year plan to determine whether its ambitions can be achieved in the timescale set out. Given the scale and complexity of the challenges facing Scotland's NHS, do you agree that much greater detail is needed if we are to get the NHS back on an even keel? A couple of points if I may. I do not disagree with you when you say that the NHS and social care are probably always under some form of pressure, but I would also say that, to be fair, if you speak to anybody involved in health and social care, they will tell you that the last two years have been unlike anything that they have ever faced in their lives. I talked to nurses and doctors who have been working in the NHS for four decades, sometimes even more, and they tell me in the 40 years that they have been working in the health service that they have never experienced anything like the last two years, nothing even comes close to it. Yes, there is pressure and then there is the pandemic pressure. The pandemic pressure is above and beyond anything that we have ever felt before. In terms of your question about more data, I think that that comes across quite strongly. It was detail, not data. Sorry, Cabinet Secretary. Data is an important part of the detail. I think that it informs a really important part of the detail. I will come back to the issue of more detail in a second. Data is crucial to that. That comes across in the NHS in the Audit Scotland report from the Auditor General. He says that there has got to be more transparency around the data. That will help us in terms of the detail that we bring forward. Yes, we will provide even more detail than we have whether that is on workforce. Of course, we are waiting for workforce plans for my health boards and plans to come forward with more detail this summer in terms of the three-year projections. We will bring forward more detail in terms of the update that we have promised to bring forward in the recovery plan this summer. Data is crucial to that. The ambitions of the recovery plan, I think, were well recognised within the Audit Scotland report. Good morning, Cabinet Secretary. When I see a patient in GP and organise an x-ray or put them on to the waiting list to see a hospital consultant, the first question they always ask me is how long is the wait going to be? I know that the Audit Committee has highlighted that. Along with Audit Scotland stating in a paraphrase, NHS boards should publish data on performance to enable transparency on how NHS boards are managing their waiting lists. Patients and doctors want to know how long patients have to wait. Why can't we have in the future, in the plan, indicative waiting times, which are relatively live so that we can all go on a website and see how long we need to wait? That would be the plan to have that data. It is a fair expectation for the patient to have. It is a fair expectation for whether there are GPs or those who work in our health and social care system to have. We expect to publish data on clinical prioritisation late summer this year. It is a new policy that is put in place to ensure that the public, the example that you have given of your patient, will be able to hopefully see how long they would have to wait. However, it will give a range as opposed to an exact date. We are working closely with the NHS and boards to develop the infrastructure in order to collect and publish the data. It is an ambition of ours to have that available in a way that is easy to find, easy to understand, both for the patient but also for the healthcare professional. When do you expect that to be online? Late summer when we intend to publish that data. However, we will have to continue to make sure that it is live, iterative and where we can add to it and develop it even further. We will do that, but we expect that the first cut of that data to be published in relation to clinical prioritisation in late summer. I'm interested in the reform as part of how we come out of the pandemic looking at technology that we have already. We saw people adopting NHS near me really quickly and meaning that people can have remote engagement with their doctors, with their respiratory doctors or their GPs. I'm assuming that that will still be part of the renewal and reform is to use the technology and innovations that we've seen and continue to utilise that so that we can help support people in the way that they choose to engage with their GPs and their doctors as well. We must embed that technology into our system. Some of that came out through necessity. We built upon some of that technology, so near me existed pre-pandemic, but it was used significantly more during the course of the pandemic than it ever had been pre-pandemic. I think that this goes back to the convener's question about being upfront and honest about how we access services. We will work with GPs to try to increase face-to-face appointments, but that hybrid model will be part of access to general practice, so telephone and video consultation will be part of that. We've also published—I think that Ms Harper will be aware—the digital health and care strategy in October last year. It's available. I'm sure that the committee members will have seen it. That really speaks and goes to the heart of what our digital ambitions are around health and social care. As the Audit Scotland committee highlights our paraphrasing slightly, it would be a wasted opportunity if we didn't embed some of those technological advances in our response and recovery to the pandemic. It's like bowel screening, and cervical cancer screening is part of the way if we can screen people early, you can diagnose early in that way, the treatment can be more efficient and beneficial as well. Cancer UK had a briefing that they sent saying that statistics published in Scotland have shown that before Covid, the uptake of bowel screening had increased. I'm in support of continuing to look at how we can improve uptake of bowel screening and cervical screening, but I know that self-sampling for cervical cancer is in the pipeline for the future. That could be a separate committee session in itself. Let me first take the opportunity to, on the record, commend our colleague Edward Minton, MSP, who I thought spoke very bravely and with great humour about his own journey in relation to bowel cancer. I managed to speak to him privately to share my admiration for that, but what I thought was really important, the message from our colleague Edward Minton, was that he was reminding people about the importance of returning those screening kits because early diagnosis could save your life. Of course, we wish him all the best in his recovery. Screening is hugely significant, and probably the most difficult decision that the Government had to make in the course of this pandemic, or certainly one of the most difficult, was the decision to pause screening very early on in the pandemic for those few months. Recovery of screening is a really important part of our recovery plan, and there are some elements of it that, for example, aren't fully recovered. If I think about the self-referral for breast cancer for women 71+, we're working on recovering that by September this year, but, for example, there's still work to do. I think that it goes back to, of course, the use of digital, but also making sure that screening is accessible as close to your home as possible. That's really important in our remote, rural and island communities. Having those mobile screening units that go around the country, for example for breast cancer screening, is going to be really important for several cancer screening to ensure that that is as accessible as possible, as close to home as possible. I think that it's going to be key to help us in our recovery. We're going to focus now on workforce planning, although we have alluded to it many times before, but specific questions from David Tons. Thank you, convener. Good morning, Cabinet Secretary, and to all other members. Audit Scotland's report on staffing recruitment stated that it would be challenging to achieve due to historical difficulties faced by NHS in the past. Is the Cabinet Secretary confident that national workforce strategy will be able to meet the workforce availability and workforce wellbeing needs of the NHS? Yes, I'm confident of that. For a couple of reasons, first and foremost, on the wellbeing aspect that you mentioned. The Audit Scotland report, I'm pleased, again, recognise the focus that the Government had put on wellbeing, and that is something that we're going to have to continue to do. It's in paragraph 89 of the report that there's a clear commitment at the Scottish Government and NHS board level to support staff wellbeing, and it features prominently in the NHS recovery plan. The fact that Audit Scotland have recognised that to me speaks volumes. I'm absolutely unapologetic about the focus that's put on this, because when it comes to issues of retention, staff wellbeing is at the core of it. Of course, pay, terms, conditions, all those things are important, but those who are telling me the thinking of leaving the NHS or social care are telling me that it is the wellbeing pressures, mental health pressures that are forcing them to think about whether to leave the profession. I'm desperate to try to avoid people leaving for that reason, so wellbeing will be central. Our workforce strategy, which was recently published and which was co-produced with COSLA, which is obviously important, particularly for the social care aspect, is going to be challenging. It's not getting away from that. We will do everything we can to try to ensure that we increase where necessary the pipeline of students coming through in particular staff and cohorts. We'll do what we can to recruit domestically. That will be a significant part of our strategy. Then there will be the international recruitment, which is not a panacea, but certainly will help to bolster some of that workforce. It will be difficult, because there are some specialities, for example, where there's not just a Scottish shortage, but a global shortage, a medical oncology, for example. There's an international challenge in that respect. Of course, we're not the only health service in the world that is facing these challenges. We're all going to be looking to try to recruit more nurses and so on and so forth. It will be challenging. Data is an issue that the Audit Scotland report focuses on in quite a lot of detail. We've got to make sure that data supporting our plans around workforce is as accurate a projection as it possibly can be. I was just coming to that. Is health impact and implementation of a strategy going to be monitored, evaluated and reported on? It will be. Of course, we will do that. At the moment, the current plans are to receive those updated projections from our local health boards. Then, of course, we will undoubtedly publish in more detail what our projections around the workforce will be. We'll continue to make sure that Parliament is regularly updated. I'm sure that those workforce plans will be regularly scrutinised by, I suspect, this committee, let alone the chamber as a whole. It's our ambition to be as transparent and open. I'd be transparent and open about the challenges, too. I've just articulated some of those, obviously, to Mr Torrance, but I think that we should be up front. This is ambitious, but it will also be challenging. Cabinet Secretary, Brexit and UK immigration policy, how has that affected the NHS and its ability to recruit additional staff? You mentioned earlier that you recruited 200 nurses internationally. Have they faced any difficulties in being able to do that? I've tried not to strain politics too much. Brexit, undoubtedly, had an impact. I think that's recognised by anybody who's involved, particularly in social care. Anybody who's even as an MSP visited their care homes and their constituencies over the past year will have seen the differences in relation to the demographics of the workforce. In any social care provider that you ever speak to, whether it's a small independence, whether it's the third sector, whether it's local authorities who have in-house provision, all of them that I've ever spoken to have said that, clearly, Brexit has an impact. In fairness, on the flipside of that, I was pleased that the UK Government, after considerable pressure from the Scottish Government and also the Welsh Government, made changes to the shortage occupation list in relation to social care as well. However, it doesn't go far enough. Social care is a real concern of mine when I talk about workforce. Of course, we've got ambitious plans around the national care service and, no doubt, in future sessions we'll get into the detail of that, but we can't wait until the national care service becomes fully operational at the end of this parliamentary term. We're taking action now, and we have to take action now, but yes, there's not getting away from the challenges of decisions that are made elsewhere but having an impact here in Scotland. On the other side of things, our homegrown workforce, our future workforce, people want to go into a profession. The Scottish Government has put in place bursaries for paramedics nurses in the midwifes. Is there any impact that that has had on encouraging people into profession? We've got positive data on the increase in student intake in nurses and midwifes, which has been positive, and that data speaks for itself. It would be difficult to say because we have the bursary that has been an increase, but it would be fair to say that the package of support that we give to students, including bursaries, has been a factor in that. The paramedic bursary is a really good example. It was an excellent campaign run by a number of student paramedics. When I met some student paramedics, we were very clear that without the bursary they didn't think they could continue. The anecdotal data is absolutely there. The workforce numbers that we have in relation to student intake is positive. There are also areas in which, historically, we have struggled in terms of intake, and they are well known and well rehearsed. My concern is often about the level of vacancy, for example, in a nursing cohort in particular. We will work hard to fill those nursing cohorts. We are in a really competitive place, because people in health systems across the world are looking to do exactly the same. I think that Scotland is a very attractive proposition with best-paid staff across the UK, but all over Scotland there is an excellent lifestyle. In particular, in remote rural and island Scotland, there is a real attraction for a lifestyle that many people seek. We will have to maximise every single one of those potential avenues to meet the ambitions of that plan. I heard the cabinet secretary's initial answer to David Torrance on workforce pressures and his last answer in terms of Brexit. When we had the Auditor General for Committee giving evidence, he spoke about the historic problems in staffing. He said that we know and have previously reported that the NHS has, historically, struggled to achieve all its staffing ambitions. Will the cabinet secretary acknowledge that there has been a historic failure and a historic challenge to deliver a workforce plan, and that there have been failures to meet staffing targets pre-pandemic? We have a good record on NHS staffing. We have grown the NHS workforce by a worth of 28,500 under this Government, or certainly since September 2006. 10 years of consecutive growth, record staffing across medical and dental consultants, nursing and midwifery, allied health professional groups, and best-paid staff. I think that our record is good, but on the flip side of that, I think that there have been challenges around our workforce planning and the projections, which can be difficult anytime—incredibly difficult and blown, frankly, off course—when you are hit with a pandemic. There is no doubt about that. That is why the projections that we will get from health boards and the data that we expect to receive from health boards this summer will be hugely important to try to ensure that, as best as possible, our workforce plans meet the demands for future years on our health service. It might be worth me being in during this, so as the director of the health and workforce, who will be able to speak or add more to that if Mr O'Kane is happy with it. Perhaps to continue the point about the planning that we have asked for. We have asked health boards to provide us with projections for workforce based on population need. That is something that will give us a much better understanding of the nature of workforce that we will need for the future. There was good work done back in 2019. We did publish for the first time an integrated workforce plan, which was across health and social care. It is important, as we look ahead, that we continue to hold both health and social care workforces together and plan on the basis of the totality of integrated workforce that we need. The planning around the summer work that we will get back, we have said, will report on later in the year. It is important that, when we look at the workforce strategy that we have just published, the strategy sets a long-term framework for the workforce. Within that strategy, there is a clear commitment to a delivery plan that will look short, medium and long term. It is within those short, medium and long term actions that you will start to see the delivery of that strategy. That is the thing that we will be reporting on on a regular basis. What you will start to see is some of the work that we are doing now. For example, those workforce projections will start to drop into the delivery parts of the workforce strategy as we move forward. Obviously, that is the sort of thing that we will be reporting on to this committee and others as we move into the future. I hope that that is helpful. I will continue in that vein across the piece. We have seen evidence from the audit report on data and planning, perhaps not being adequate. That answer suggests that we have to do a lot more in terms of understanding and profiling where we are. I can return to the cabinet secretary in terms of nursing places and nursing vacancies. We know that there are 6,674.4 whole-time equivalent nursing and midwifery vacancies in the NHS. We have heard some of the reasons that the cabinet secretary would offer in terms of the challenges that are there. Will the cabinet secretary accept that, over many years, the reduction in nursing training places, for example, a decision taken by his predecessor has exacerbated the situation in terms of the challenges that exist? I appreciate what Paul Cain is trying to do, but I will go back to what I think is a really good record of this. I am trying to ask your question and get the answer. Over the course of our time in Government, our record speaks volumes in terms of recruitment and trying to look into the future, or even looking at the present vacancies that exist. Vacancies are undoubtedly a part of expanding the workforce. We have to create vacancies in order to expand the workforce. I will be able to write to the committee with more detail about what percentage of recent vacancies have come on board recently. In fact, Gillian is healthy provided that 77 per cent of the nursing and midwifery vacancies reported December 2021 have been recorded in the last three months. That is reflective of the extensive new posts that have been created. Vacancies are undoubtedly a part of the expansion of the workforce. It does not account for all those vacancies by any stretch of imagination. Those vacancies give me a level of concern. I go back to the point that I made previously under this Government, where there is a good record of increasing and expanding our staffing. What I would say is that it is not just about the expansion, it is about retention and the nurture pillar of our workforce strategy is key to that. It is also about, in the reform space, what we ask those who are working in a health service to do and a question about, in the future, infinitely growing our workforce. I do not think that anybody would suggest that that is possible to do infinitely, but what we can do is ensure that what we ask our workforce to do meets the needs of the public and patients. I think that we have a good track record. I do not doubt that there have been challenges in workforce planning in the past and, hopefully, with our current strategy in place, we will be able to mitigate some of those challenges. A number of colleagues want to come in on workforce planning. Can I ask for short, sharp, succinct questions? Can I come to Emma first and then I will come to Sue? I will be quick. The SCOTGEM programme was launched in 2018, and it is unique to Scotland. We have just seen 54 graduates come out of that. That is part of the way that we are trying to address GP recruitment for rural areas as well. A quick comment on how successful SCOTGEM is for Scotland. It is really successful, and I take a cue from the convener about being succinct. There is little for me to add to that, because Emma Harper has rightly mentioned some of the data on the SCOTGEM programme. I think that we can build upon some of those initiatives. SCOTGEM rediscovered the joy programme, Golden Hallows, for example. The work that we are doing on the back of Professor Lewis Ritchie's report in relation to the Centre for Remote and Rural Health Care. I think that all those initiatives are incredibly important for recruitment retention, particularly in the remote rural and island settings. I know that we have spoken at length and you mentioned that retention is key. The Royal College of Midwives research is damning. It says that midwifery is at breaking point. Three in four RCM members in Scotland are considering leaving their posts while 88 per cent are reported experiencing work-related stress. NH boards are encouraged to optimise the retention of midwives, and yet midwives are telling us that that continues to be a profession in crisis. What immediate action is the Scottish Government taking to respond to the concerns of midwives right now and to improve their retention and their health and wellbeing right now? I spoke to Jackie Lambert of the RCM yesterday. We had a good detailed discussion around the very points and miswebber references. I do not know if the staff survey is published yet or not, so I will perhaps refrain from going into it in detail until it is published. In my understanding, the best things that we can do to try to alleviate some of those concerns is one control Covid transmission, because it is very clear from the staff responses that the pressure of the pandemic has been unlike any other pressure that they have faced before. If we can control Covid pressure, it will stop midwives from having that anxiety every day. They go into a shift, whether they will be moved to a different ward or whether they will have the appropriate number of midwives and nurses in any given unit or time. Controlling Covid transmission is going to help us to alleviate that significant pressure. Both investment and wellbeing, but also giving time to our midwives and other NHS and social care staff to access those wellbeing resources, will be really important. I made a commitment to the RCM that we would absolutely continue to invest in that wellbeing. The third point that it made to me quite strongly was about the importance of time for training and educational and professional development, which has again been impacted by the pandemic. If we can control the pandemic, control community transmission, that begins to alleviate some of that pressure, where we can dedicate more of our time to that training and professional competency aspect. Cabinet Secretary, where are the bottlenecks on a patient journey through the NHS? I think that there are a number of bottlenecks given the pressures of the pandemic. I think that some people will, for example, say to me that their challenge is accessing primary care, so we know that there can be challenges in that respect. I think that you referenced an example of a patient waiting for an x-ray, accessing diagnostic testing, waiting for elective procedures, all of that has been or screening. We talked about that previously, all of that has been impacted by the pandemic. There were no doubt challenges with waiting lists, for example pre-pandemic, but anybody, and I am not suggesting that you are saying this at all, but any suggestion that the pandemic hasn't significantly exacerbated those problems, I think, would be inaccurate. I think that there is, unfortunately, due to the pandemic bottlenecks across the system. In the interest of time, perhaps, just a commitment, even with the cabinet secretary on this. I just wanted to raise the important issue of the allied health professional staffing, who I think have a really important role in the reform of the NHS, but also have significant recruitment and retention problems. As I say at the moment, it was just to raise it to ensure that the team did see it as an important part of the overall plan for the NHS. Yes, vital, vital. There's not much for me to say other than to agree ferociously with Ms Malkin on that point. We know how important those allied health professionals are, particularly if I think about the work that we're doing with GPs and those multidisciplinary teams, for example. That's just one example of how important vital they are. They're clearly part of our recovery plan and part of our recovery of the NHS in social care. Thank you. We're now going to move on to talk about long Covid and Emma Harper. Thanks, convener. I'm interested in looking at how we're going to support people who have the post-Covid syndrome. Lots of different symptoms seem to be demonstrated, whether it's neurovascular or cardiovascular. It's a gastrointestinal musculoskeletal. Lots of range of symptoms. I'm wondering what are we doing in Scotland to help support people with long Covid? The question is obviously a focus of the Audit Scotland report, and I'll give a response to Ms Harper. I suspect that we'll get into more detail in this in the forthcoming parliamentary debate on this. I meet stakeholders, particularly those with lived experience of long Covid, fairly regularly. Not just adults, but including long Covid kids, who are an important organisation representing young people that have been affected by long term. It's fair to me that they feel that there's not consistency around the approach, both from a geographical perspective, but also in terms of various different parts of the healthcare system. That's a key challenge that they've put back to me in that respect. What are we doing to support? Well, as the member will be aware, of course, we try to provide as best guidance and as much guidance as we can to our clinical colleagues in healthcare. At primary care level in particular, they will often be the front door where people will go to first and foremost if they're suffering from long Covid. If I look at the notes in the same guideline, for example, as services for people with long Covid, it may be provided through integrated and co-ordinated primary care, community rehabilitation and mental health. The guidelines also show that areas have different service needs and resources, so not one model will fit all areas. There's a difference in approach taken in different parts of the country. You'll know that we announced £10 million for a long Covid fund to be spent over three financial years and we'll soon be able to give detail of how some of that funding will be distributed. I think that one of the key things that we've tried to do to deal with that consistency question is the establishment of that national strategic network for long Covid. That network, although it's managed by the NHS National Service of Scotland, it brings together clinical experts, it brings together GPs, allied health professionals, specialists in secondary care, but most importantly it brings together those with lived experience and informing us on how that funding should be spent, where are the gaps in provision, where are the gaps in services, etc. The network will examine and continue to be a check on the work that we are doing collectively on the issue of long Covid. I think that there's a lot more to do in this space and the last thing I'll say on this is that clearly we are still learning about the long-term impacts and effects of Covid and therefore we provided funding for research in that respect. Research takes time and that's maybe not an immediate action or not an action that we'll see an immediate result or benefit of, but certainly that research is going to be critical to our understanding of how we treat and manage long Covid in the future. The long Covid networking will take place virtually with clinicians and professionals. We're not necessarily talking about bricks and mortar clinics spaces, we're looking at some virtual engagement as well, like it's taking place in England as well. Is that part of how we will support people going forward? I suppose that I'll go back to the guidance note that there's not one model that fits all. For example, if a health board wanted to set up a clinic based on the Hertfordshire model, they could do that and they would be able to do that. Again, I won't pre-empt any funding decisions that are still being considered and will obviously make that fully public and transparent soon. I think that it's up to individual health boards to understand the needs of those that they serve, what is the best model for them, that they can put in place, and I may know in some places that works exceptionally well, so I spoke to a patient Pamela from. She was in the Greater Glasgow and Clyde area and she had had exceptional treatment and care for the long-term effects of Covid. I couldn't speak highly enough of the physios in particular who had helped her in the course of her care and her treatment. I've equally spoken to people who say that the support that they've received has been inadequate in terms of the long-term effects of Covid. That's where we've got to make sure that the strategic network ensures that there's consistency across the country. Of course, my job is to ensure that that is resourced effectively. It's just to pick up again across the country. We've got urban and rural and remote areas and islands, so we do have a different geography in order to support people. We can't just lift and shift a model that might be used elsewhere, but I suppose that we can learn from what they're doing in France, Belgium and Germany as well. We should learn from good practice across the UK, across Europe and across the world where we can. There will be absolutely good practice going on and where we can replicate that and it's appropriate to replicate that in Scotland. We will do that, but I have a high degree of trust in our health board colleagues to be able to deal with and treat and provide care for people with long Covid in a way that suits them. We will use their particular demographic and their particular challenges if they are remote, rural and island in particular. That is going to, no doubt, be an evolving picture. I'll continue to keep Parliament updated. The use of technology, no doubt, will be important in that, but equally, as our understanding develops through research, so too will our approach develop to, I suspect. I'm glad that Pamela had a great experience. Unfortunately, she's a bit more of the exception rather than the rule when it comes to long Covid. I'm glad that you also mentioned the Hertfordshire model, which is something that could be used throughout the country because it does a lot of its work virtually because that's how the patients want to access the clinic. A lot of long Covid patients physically coming into a hospital, into a clinic space, they're too tired and they can't access it. The Hertfordshire model, despite what we've heard earlier, could actually work throughout the country. When you spoke about the guideline, Mae was one of the big words in the guideline. Surely, we need to get to a position across Scotland where there is a clinic that GPs can refer patients into because right now what we've got is not acceptable. I think that there's a difference of view from clinicians. Of course, I would respect your clinical judgment in that respect, but there are many clinicians that you would acknowledge that have a different view that actually a one-stop clinic that you could refer into would actually end up taking resources away from other parts of the health service where actually we could refer people into a respiratory pathway or into a different pathway. There's not that need for a one-stop clinic. At the same time, I would accept the counter-view to that, which I think I was trying to hopefully be fair in my articulation to Ms Harper, where there are good models, and I purposely referenced the Hertfordshire model, where there are models that we think can be replicated up here in Scotland. I have no issue with health boards replicating those models, implementing them, embedding them in their health board area. As I say, we will shortly be able to give detail once final decisions are made about funding in relation to the £10 million long Covid fund. The purpose of that fund is to say, where are the gaps in provision? Can the funding help to plug some of those gaps? If a health board believes that there should be a one-stop clinic, then fair enough. However, NHS Highland is a classic example of how challenging a one-stop clinic might be. You can access virtually—I take your point—that virtual can absolutely be a critical part of that. For many people, the expectation of that clinic will be that we will be able to see a clinician go face-to-face where they can and have a detailed conversation face-to-face. We have to be upfront that that model, for example, may work in some areas that may not be suitable for others too. On long Covid, can you be quick, please? I've got Paul wants to ask a question. We've got several other themes to get through. When the Auditor General came before us, he said that it will be difficult to evaluate how long Covid patients' outcomes and how they get on through the services. With the money that's being spent, will you ensure upfront that we embed a way to see how long Covid patients get on with their journey and also see and evaluate the outcomes with those outcomes published beforehand? Yes, evaluation will be a critical part of any funding that we give. That goes for any portfolio, but I'm particularly keen that that evaluation is embedded within any of the funding related to long Covid. Again, it's a condition that we're learning about. I can absolutely commit to the exact timescales of that evaluation. I'll take that off a table and furnish you with more detail in that respect. The evaluation of any model has got to be critical because we are learning about long Covid day-on-day, day-by-day, week-by-week. The strategic network will have a role to play in that evaluation. I should say that everybody in that strategic network is important, but those will agree with me on this point that the most important people are clearly those with lived experience. That feedback loop that we have with them for me is crucial in any evaluation. On the £10 million fund, it was announced in September of last year. However, no spending until the beginning of this financial year. I think that you just understand why that was and what the long-term strategy is in terms of funding this crucial work. We were always up front about the fact that it would be for the next three financial years. Obviously, we're in one of those financial years now. The reason for taking some time was, and not to rehearse this point too often, but it was crucial that we understood where the gaps in provision were. That was informed by clinicians, health boards and those with lived experience. That allowed, when we did a detailed consideration of that, health boards and others to bid in for some of that money to hopefully be able to plug some of those gaps in provision. It's really important that that work was done. I'm confident that the first tranche of that money being disembursed will make a considerable improvement in regard to the experiences of people suffering from the long-term effects of Covid. However, as I keep saying, that will be work in progress because we're learning more and more about the condition. Therefore, our approach should, as a result, develop too. We're now going to address data. We have questions led by David Tollans. Thank you, convener. Good morning, everybody again. In a conversation at a weekend with friends when we were socialising, and they're all front-line staff, NHS staff, Audit Scotland's call for more data, their faces just went, because they feel that the collection of it and the time they've got to spend on it detracts them from front-line services. Where is the fine balance here? If Audit Scotland wants more data, more data, more data, front-line services and backlogs are just going to get bigger and bigger and bigger. How do we get a balance here? I think it's a really good point for us, but I'm really pleased that Mr Tollans has time to socialise. It's dreadful. I won't tell you what we're celebrating. No, I'm quite right. It's nice to get back out and socialising now that we can, of course. To the serious point in his question, there's a balance that needs to be struck. I'm very conscious of this, because I've asked for a lot of data from our healthcare colleagues in the course of the pandemic and the year that I've been health secretary. Government has asked for a lot of data, and that's put undoubtedly some level of strain, so we try to get that balance right in terms of how often we're reporting, what data we're reporting on, etc. The key issue around data that we make into this in more detail that I hear from healthcare professionals is just still some of the barriers that exist between sharing data across the health and social care landscape. It continues to be a really significant problem in our data strategy. I did still a health and care strategy that was published last year. It certainly lays the foundations of easing some of that in the future and removing some of those barriers. I think that your point about making sure that we absolutely have the data that we need, but making sure that we don't burden our health services at a time of extreme challenges is something that we're very alive and alert to. Will the forthcoming data strategy directly address those gaps in data identified by Audit Scotland in primary care and community care data, or is the Cabinet Secretary thinking that it will be more of an overarching strategy? That's a really good question. The gaps that we see at the moment are the barriers that we see at the moment. That sharing of data, to remove those barriers, is already in place. It doesn't need necessarily another strategy or another document. That issue is well known. It's issues that we're working on for many years and we'll continue to try to work through some of those issues. If you look at our digital health and care strategy that was published last year, one of the key aspects of that strategy, one of the key aims, and the second of those key aims is the sharing of that data, a system that allows staff to record, access and share relevant information across health and care systems. That is really important. That is done in a way that, of course, removes those barriers, but also, frankly speaking, we're able to do within the financial constraints that we're under. If I went to page 17 or 18 of that strategy, it talks about our digital foundation. It talks about the national digital platform and how the cloud-based infrastructure is going to be so, so important. That isn't about appending every single IT system across the NHS and social care and completely replacing it in its entirety with one system but using that cloud-based architecture, which can allow you to share information better. Yes, the digital strategy will be overarching. It will talk about how important it is for people to be able to access their own data, how that data will be safely managed, stored ethically managed and so on and so forth. It will also ensure that the strategy will also be an iterative strategy, so it will continue to be developed as well, but it won't delay any of the current work that's being done to address the issue of availability of data, whether that's at primary care, secondary care or community level. What will the data strategy do to improve data on health inequalities? We've heard in other pieces of work issues around data specifically relating to different minority ethnic groups and things like that. It's an area that I'm quite keen that we continue to work on to make sure that everybody's healthcare matches the reality of their lives. You've consistently raised that issue around health inequality when I've been in front of committee and it's an important issue for us to focus on. Collectively, I go back to my substantial point to your previous answer, which is that the work that we're doing around data on health inequalities isn't going to wait for the strategy to be published. We're getting on with that work just now, so if I gave you just a couple of examples, you'll know that during the course of the vaccination programme, we ensure that we collect the data on people's ethnicity. For example, when I gave us much richer detail around some of those health inequalities, it's very clear that the uptake of the vaccine was lower amongst particular ethnic minority groups such as the Scottish African population, for example, the Polish population as well. We're doing some of that. The other example around some of that would be the great work done by the health inequalities and primary care short-life working group and much of that work involves some of the colleagues from the deep end project, which of course, as you know, is GP practices that are focused and based in some of our most deprived parts of Scotland. I commend that report to everybody in the committee if they haven't seen it. The data strategy itself will absolutely set the direction for improving data collection recording of protected characteristics data, which will allow for research into health inequalities in a great amount of detail. There will be that element to the data strategy, but I just want to give Ms Mackay an assurance that we're not waiting for that strategy to improve the data collection on health inequalities. That work has taken place right now. I think that everybody here would agree that improving population health is going to be really, really key going forward. Life expectancy, particularly healthy life expectancy, physical health, mental health and wellbeing. Covid has shown us the importance of those things as well, but we're also in a situation where we're recovering from Covid. Is the health and social care sector recovers? How can you ensure that policymaking really remains focused on prevention and early intervention? On prevention, I can give you confidence that this is not seen in isolation in health and social care. It is, of course, vitally important for us in health and social care, but the work that the Deputy First Minister does in convening a group of a number of cabinet secretaries and ministers together with a great degree of regularity is focused on almost entirely on prevention. A recent announcement around the child poverty action plan, for example, is an excellent example of a number of portfolios coming together to say that we're going to work hard to deal with this issue of child poverty as it exists, but also in the preventative space to prevent further young people, children and families getting into poverty. Here's how we plan to do that. Cross-government, cross-portfolio working is vital. I think that improving physical and mental health before crisis point is going to be a real important focus for us. There's a lot of focus that goes into CAMHS, understandably so. There are challenges around CAMHS referrals, and I accept that. That's why we'll put in significant investment, but we're also putting in significant investment into prevention before we get to crisis point. What can we do with our schools, for example, with education and around mental health? As well, in terms of physical health, there's a lot in the preventative space. How do we make physical health opportunities sport more accessible? It's not something just for those who are at an elite level, as important as that is. I've celebrated about 10 years of the Daily Mile. Last week, my colleague Marie Todd has to get a shout out for her vociferous championing of that particular project. We're trying to make physical health, and our opportunities to improve physical health as accessible as it possibly can. If I can give you an absolute assurance that we've got a laser-like focus on the preventative agenda that I've done for many years, I'll go back to the point that Ms Mackay raised, that our data in and around those areas of highest deprivation and where health inequalities, unfortunately, are still too wide, those areas are going to be areas of particular focus for us in the coming period. There's so much work around 20-minute neighbourhoods and everything as well, having services based on the communities where people are as well. I appreciate all of that. Certainly one of the things that we've come up against when we've been talking to people from the NHS is the fact that, quite often as well, it's what they're targeted on, that they tend to be driving towards, and it can be much more difficult for them to prioritise the preventative work there. What kind of stuff can be done to empower them to ensure that that work is really at the top of their priorities? Is there a monitoring and evaluation that we can be looking at alongside that? A lot of our funding streams, for example, are focused on that preventative spending. I should commend the third sector for the role that they play. We often talk about the important role of our public bodies. Of course, they play an exceptionally important role in all of that, but I think that the third sector has a vital and critical role to play in the preventative agenda. Our funding will often be targeted in that preventative space. Of course, that funding, as I mentioned in the previous answer, will always be evaluated in terms of outcomes and what is achieving in terms of outcomes. We also have an important role in the policy making and what can help in that preventative space. If I think about some of the action that we've taken around smoking cessation, obesity, alcohol consumption, our policy has to be focused on that preventative space. It's also why I'm very keen that when we talk about health and social care, we don't lose focus on the social care aspect because the more we can resource our social care and care in the community, then we hopefully prevent people from coming in the front door of our hospitals. Even if they do have to come in the front door of our hospitals, hopefully they are for a relatively short period of time, and certainly we wouldn't want to see the level of delay discharge that we're currently seeing at the moment, which I fully accept is far too high. So, important role in terms of funding, important role in terms of third sector public bodies, but also government obviously leads on this agenda and our own policies. I hope to give some reassurance that this is a top priority for us. Just one more short question, convener, if that's okay. So, just very, very specifically Cabinet Secretary, progress and life expectancy has stalled over the last period, and I'm wondering if there are any specific plans to revitalise that progress there? Yeah, it has stalled. You'd be right absolutely in making that point. I think improving mental health and physical health, which are often linked obviously, so improving access to opportunities to improve one's own physical health and mental health are going to be clearly critical to that. I think that's why recovery plan is so important to be frank over the last two years because people haven't been able to access services in the way they would have pre-pandemic. There is undoubtedly people are attending our hospitals with higher acuity, the deteriorating in terms of their own conditions if they're waiting on waiting lists for too long. If you don't get a CAMS referral in good time, of course your mental health is in danger of deteriorating. So this preventative space, again, is integral to our recovery, but the challenges are significant and that's why the care and wellbeing portfolio is also hugely important as well. I'm happy to give you continued updates on how we're evaluating that because different pieces of that work will be evaluated in different ways, so we've promised to update on the recovery plan for example yearly on funding streams as a different evaluation process, so maybe I can set some of that out in further detail to the committee. For a deeper dive into health inequalities, Carol Mawkin. Thank you. The previous couple of themes have covered that, but the Auditor General was quite critical of the Government in its overall strategy for addressing health inequalities, particularly around disability and those from deprived backgrounds. In terms of the pandemic, I very much acknowledge that this is on-going health inequalities, as we've heard. I'm really keen to find out from the Cabinet Secretary, you know, have they managed to pull together an overarching strategy to look at health inequalities and what actually are you going to measure. On top of that, I wonder if the Government has considered other measures that it can use, perhaps other powers that it's not currently using within the Scottish Government to make a difference to what is probably of the highest importance for the Scottish Government. I recognise from the offset that Ms Mawkin has had a consistent interest in the issue of health inequalities, and it's an interest that I share with you to go to the heart of what we're doing right across Government. I commend in terms of health inequalities the report that I referenced to Ms Mackay, the health inequalities and primary care report, if you haven't seen that, and I appreciate how much paperwork members will see on a daily basis. We're keen to share that with you, so we'll make sure that, if you haven't seen that, we'll pass a link on. The recommendations of that report are really important for Government to consider the provider really strong basis for dealing with health inequalities in terms of a primary care level, which we know will often be the first port of call. We've obviously invested in community links workers and have promised a further investment in mental health and wellbeing workers in every GP practice as well. In terms of the powers that we have, I won't give you a long list of what we've done, maybe just a short list perhaps, but there is the work that we've done across both worlds. I think about education, I think about providing free school meals in early years, the number of hours of free childcare, but particular focus on at-risk and vulnerable young people. If I think about the work that we've done in investing in housing and affordable housing, I think about healthcare, I think about the delivery of a number of preventative programmes and policies that I've mentioned in the public health space. I can think about concessionary travel, free personal care and so on and so forth. You're right that this is a cross-Government approach in terms of tackling inequalities. I have to be up front and frank, and I think that Ms Malkin would accept this to some degree. I hope that there's only so much we can do when we have a UK Government that I don't think is adequately addressing the cost of living crisis. I don't think that it's adequately addressing the issues around fuel poverty, the energy crisis and, frankly, the Government that it's the passive nature in which it's tackling the cost of living crisis comes in the back of 10 years of really difficult austerity that we had too. Some of those powers are absolutely in my hand and I would expect Ms Malkin to rightly challenge me to go further, to use them more and so on. We've often done that, but, frankly speaking, there's only so much I can do to mitigate the impacts and effects of decisions that are made elsewhere. I thank the cabinet secretary. Obviously we would agree that the cost of living crisis is very significant and we don't disagree on the impact from the Westminster Conservative Government absolutely, but I do thank him for the commitment to look at ensuring that we are using all the powers here in Scotland, so that's very helpful. I wonder just one of the last things that the Auditor General had spoken about was the progress of the Public Health Scotland work and I wonder if you could just give us a little bit of a feedback on how you feel that is going. I think that most members, I hope, would recognise the incredible work that the Public Health Scotland has done over the course of this pandemic, the amount of data that they've provided us, the incredible work that they've done right across the range of services that they've provided in relation to the response to the pandemic. That means that, essentially, some of the work that we'd wanted Public Health Scotland to do when they were initially conceived or thought about conceiving Public Health Scotland as an organisation, we never knew we'd be hit by a pandemic. So some of that work has stalled. There's no getting away from that. In my recent conversations with Public Health Scotland, though, I've been pleased that there's been much more of a focus, not entirely pivoting away from the pandemic response, because that's still with us, but certainly being able to pivot slightly away from that pandemic response, given that we are moving into an endemic phase and working more on exactly the type of issues that Ms Malkin has already raised. I can give you an absolute assurance that that is from the management and the chair that I have spoken to. That's a clear focus for them. We have questions on the finance of NHS Paul Kane. The Audit Scotland report states that the NHS was not financially sustainable before the Covid-19 pandemic. It goes on to talk about the six boards that are requiring additional financial support from the Government, or indeed taking non-recurring savings in order to break even. I wonder if I can start with those six boards in terms of my questions. Is the Cabinet Secretary confident that those boards will be able to achieve financial balance in 2022-23, or is on-going support likely to be required? What is his assessment of the issues being experienced by those boards? Is it weak financial management, or does he think that it's more fundamentally a lack of adequate resourcing? The first thing to recognise in all of this is that, when it comes to the response to the pandemic, we have ensured that every single health board has received the support that they have needed. Where they have requested additional support, we have been making that available, but there is no doubt that those boards that were escalated in relation to financial sustainability were escalated prior to the challenge of the pandemic have not made that easier. Significant support has been provided to the board. I'm not going to give you an absolute in terms of where to end up at the end of the financial year, but I think that there's going to have to be continued work with those boards in the period ahead. My aim and ambition in providing that support is to see a de-escalation. That's the entire purpose of providing that support. When those boards are escalated, you'll be absolutely aware that we ask for a significant amount of additional reporting than we would for any other health board. I'm confident that they'll de-escalate in good time, but I would also make the point that the pandemic has made that issue of financial sustainability more challenging. I don't know if Richard Wharton wants to add anything further in terms of those specifics. A couple of things. As the cabinet secretary has said, all boards received additional financial support through the pandemic. We provided that additional funding, cost associated with bed capacity, with the vaccinations programme, etc. All boards received that additional funding. Of the six boards that are mentioned in the Audit Scotland report, three of them were escalated for financial reasons before the pandemic, so Esher, Aaron, Borders and NHS Island. The work that we did at the end of 2021-22 was to enhance the financial reporting that those boards did just to ensure that, given where they were before the pandemic, there was still that ongoing focus on financial recovery. With the three other boards of those six, NHS Orkney, NHS Dumfries and Galloway and NHS Fife, we'd noticed some differences in terms of their position compared to other territorial boards. The approach was to have some of that enhanced reporting just to be sure that the boards were on track with their financial plans with very much, as the cabinet secretary has said, a view to ensuring that in 2022-23. They can deliver the financial plans that they've set out. Thank you, convener. I don't think that anyone would deny that the pressures have been exacerbated by the pandemic, but I was just pointing to the fact that the Audit report does say that there wasn't a financial sustainability. Prior to that, I think that committee will be keen to hear an update on the progress of those boards that I've referenced when we get to financial year end. I wonder if I can, convener, just perhaps go on to talk more broadly about the increase in funding. The Scottish Government committed to a £2.5 billion increase in funding for health and social care. That's over, obviously, the course of the Parliament, but the medium-term financial framework for health and social care has not yet been updated. So, in the absence of any medium-term financial framework, how can the cabinet secretary be confident that the additional funds committed will actually be allocated and indeed used effectively? Can I also just ask when will the updated medium financial framework be published? We've recognised that it has to be updated, particularly in light of Covid and some of the challenges that that has brought. I don't think that we've committed yet to a specific date on when it needs to be published, given that we are just coming out of the immediate pressures of a pandemic response, given the Omicron and BA2 wave, but we do recognise that it needs updated and published. In terms of the resources and demand, the medium-term framework does not set a budget. It gives us an envelope and then it's for us to prioritise what the budget will therefore look like. That's informed by our key policy priorities and areas, how to be aligned with the national performance framework and so on and so forth. In terms of your question, which is about confidence in the funding and the financial fiscal framework, I would point to a recent joint study by the London School of Economics, LSE and Lancet, suggesting that a 4 per cent real-terms growth in healthcare costs is to be expected to ensure an improving quality of care and terms and conditions for health and care workforce. That is very much in keeping with the underlying assumptions that underpin the current medium-term financial framework. This and other independent research will inform our review moving forward. In terms of the publication of the medium-term financial framework, we will update that and publish that, but we will do so after the resource spending review, which I hope would make sense to most members around the table. The Auditor General noted that reforming lines of accountability might encourage more collaborative working across health boards. He noted that individual accountable officers could be measured on delivery of performance in their own organisations as opposed to wider outcomes. Is that something that the Scottish Government is exploring? I will give it an explanation. I think that every Auditor General's report into the NHS deserves rightly that consideration. I am really keen that we get the balance right between reform, which is exceptionally important in terms of delivery of service, but also where we can reform governance and accountability. We do not end up so distracted by that. We get distracted from the immediate pressures that we are under in terms of getting through that backlog, given how long people have had to wait for various legal procedures. The accountability point is an important one, although I could not give a commitment to in terms of what more we might do in relation to the Auditor General's recommendation. It is certainly one that is worthy of further consideration. Thank you very much Cabinet Secretary for all your responses today. We have run out of time, unfortunately, but I thank you and your officials for the time that you spent this morning. At our next meeting on 17 May, the Minister for Mental Wellbeing and Social Care will be attending the committee to provide a general update on the social care sector in Scotland. This follows the publication of Audit Scotland's social care briefing on 27 January and the evidence that the committee heard on 22 February from a number of stakeholders representing the social care sector. That concludes the public part of our meeting today.