 Good morning and welcome to the 16th meeting of the health and sport committee. I would ask everyone in the room to ensure that the mobile phones are on silent and it's acceptable to use mobile devices for social media within the room but please don't take photographs or film proceedings. The first item on the agenda is subordinate legislation with two negative instruments. The first instrument is the national health service, dietary supplement prescribers and therapeutic radiographer, independent prescribers, miscellaneous amendment, Scotland regulations 2016, SSI 216393. There's been no motion to annul, however, the delegated powers and law reform committee have made comments on the instrument and they draw attention of Parliament to under reporting ground H on the basis that the instrument could be made clearer in the following respects. Under I, in regulation 3b2, the word or could be used instead of and and at the end of subpargaf F of the definition of prescriber in regulation 2.1 of the NHS general medical services contracts, Scotland regulations 2004. That would put me on doubt that the subcategories listed in that definition are alternatives and not cumulative. The second point is 2 on the basis in regulation 6b2, the word or could be used instead of and at the end of subpargaf F of the definition prescriber in regulation 2.1 of the NHS primary services section 17c agreements, Scotland regulations 2004. The delegated powers and law reform committee have confirmed that no changes shall be made by the Scottish Government. I invite any comments from members. No, everyone is satisfied. Is it agreed that the committee make no recommendations? That is agreed, thanks very much. The second instrument is patient rights, complaints procedure and consequential provisions Scotland amendment regulations 2016, SSI 2016-401. There's been no motion to annul and the delegated powers and law reform committee has not made any comment on the instrument. I invite any comments from members. No, the committee agreed to make no recommendations. The second item on the agenda is an evidence session on the draft budget 2017-18. I welcome to the committee Shona Robison, cabinet secretary for health and sport, Christine McLaughlin, director of health, finance and Paul Gray, director general health and social care and chief executive NHS Scotland, all from the Scottish Government. I invite the cabinet secretary to make an opening statement. I think that, as agreed with your office, you would make some reference to climate change issues in your statement as well. I thank the committee for the invitation to discuss the draft budget for 2017-18. I welcome the opportunity to give evidence this morning on this very important subject, ensuring that the fair and appropriate funding for the national health service and asset, of course, is precious to us all. Over the next few years, the demand for health and social care and the circumstances in which it is delivered will be radically different. NHS Scotland must work with its partners across the public and voluntary sectors to ensure that it continues to provide the high-quality health and care services that the people of Scotland expect and deserve, securing the best possible outcomes for people through the care and support they receive. As I have highlighted before, the NHS simply cannot stand still but has to continually evolve to deliver the best medicine and the best care, always ensuring that public money is spent as effectively as possible. It is with that in mind that we published yesterday our delivery plan for health and social care. That plan brings together the key programmes of change for ensuring that our health and social care system can meet the new challenges, particularly the national clinical strategy, health and social care integration and public health improvement. The delivery plan sets out high-level actions and we look forward to working closely with COSLA, employers and staff-side partners in NHS Scotland and a range of others to deliver our aspirations. At the core of that delivery plan and our overall approach are the twin themes of investment and reform, and those themes are also at the heart of the budget. In addition to providing extra financial resources, we will continue to drive forward our significant programme of reform and this budget sets the framework for our next steps. We have consistently prioritised investment in the NHS and have increased front-line health spending between 2010-11 and 2017-18 by 9.3 per cent in real terms. In 2017-18 funding for our core NHS budgets will increase by over 320 million pounds, more than the Barnett consequentials for health, which was 304 million pounds. Also through an additional 50 million pounds to be directed to Enrack parity, no board will be further than 1 per cent from parity in 2017-18. This reflects the priority that this Government places in protecting front-line services and ensuring an equitable distribution of resources. We will continue to demonstrate the central priority moving forward. The NHS revenue budget will be almost £2 billion higher at the end of this Parliament than at the outset. Our commitment to integrating health and social care services is demonstrated in this budget, with additional investment of over £100 million to be allocated to health and social care partnerships. This will bring the additional NHS investment in health and social care integration up to almost £0.5 billion in 2017-18, allowing key services to be delivered differently, with greater emphasis on supporting people in their own homes and communities. As well as progress with integration, this budget sets out further measures to shift the balance of care by increasing in every year of this Parliament the share of the NHS budget dedicated to mental health and to primary community and social care. The budget represents an important step in ensuring that, by 2021-22, more than half of front-line NHS spending will be in community health services. We will invest £72 million in improvements to primary care and GP services, going towards an additional £500 million being invested in this area each year by the end of this Parliament. By 2021-22, we will increase spending on primary care to 11 per cent of the front-line NHS budget. In 2017-18, investment in mental health will exceed £1 billion for the first time, and we will see mental health investment exceed £5 billion over this Parliament. That will help to underpin our new 10-year mental health strategy, which will be firmly based on the principles of ask once get help fast. Our capital investment programme will ensure that the NHS estate is equipped for the challenges ahead. It will invest over £200 million in the NHS estate, focusing on improving primary care facilities, maintaining and updating medical equipment and replacing key vehicles such as ambulances. Furthermore, we will prioritise investment in the new Dumfries and Galloway royal infirmary, the new sick children's hospital and department of clinical neurosciences in Edinburgh and the Baird family hospital and anchor centre in Aberdeen. The draft budget also commits to progression on our £200 million commitment to expand the Golden Jubilee hospital and create five elective care centres in Aberdeen, Dundee, Edinburgh, Inverness and Livingston. That will, for example, allow us to meet the increasing demand for hip and knee replacements and cataract operations. Dedicated elective capacity will help to tackle the knock-on effect that peaks in demand from unscheduled emergency patients can have on planned elective care. In this global and interconnected world, it is more important than ever that we all consider the impact of our work on wider issues, in particular that of climate change. The NHS, Scottish Features Trust and Scottish Government have been working closely in partnership to develop and procure a Scottish energy efficiency framework that will permit vital energy efficiency work to be carried out using both capital and revenue funding. Recent capital funding has been directed to a number of NHS capital projects such as the replacement of boilers in Glasgow Royal Invermory and St John's Hospital in Livingston to improve energy efficiency. In 2017-18, we are planning to provide capital investment of £1.8 million to energy efficiency projects in NHS Tayside and NHS Ayrshire and Arran to help to lower our carbon emissions. I conclude with my opening comments around investment and reform. It is through this approach of continued investment and reform that we will set the basis for delivering the 2020 vision and our longer-term strategy up to 2030 through the delivery plan that we have published. That will ensure a safe, sustainable and person-centred NHS for the people of Scotland. This draft budget for 2017-18 puts in place the framework to enable us to achieve this vision and, on this basis, I commend it to you. In the budget document, we have a 0.6 per cent increase in real terms in the allocation. Audit Scotland said that the rate for health inflation is 3.1 per cent. Are we in effect seeing a cut? First of all, NHS territorial board budgets will increase by 2.8 per cent in 2017-18. That includes the baseline uplift and enrack parity and baseline transfers. If you look at the health service inflation figure, it is 2.3 per cent. The allocation to territorial boards is higher than the inflation for 2017-18. Of course, what is required through the reform process, which I have laid out very clearly in the delivery plan that we published yesterday, is the need for us to continue to drive efficiency to make sure that we can invest in the transformation that we require to invest in. That is why, for example, in 2017-18, £128 million went into a change fund that will help us to shift the balance of care from the acute sector in hospital-based services into the community. Although there is an above inflation increase for boards, we also recognise that the services that are delivered need to change in order to maintain the quality. Across the health and sport budget, the allocation in total is £13.2 billion, which represents a 2 per cent increase or a 0.6 per cent real terms increase. At the same time, Audit Scotland's figure is that health inflation is 3.1 per cent. That was for 2016-17. It decreases to 2.3 per cent in 2017-18. So there is still a gap between 0.6 and 2.3 per cent? No, because the territorial budgets are receiving 2.8 per cent, which is higher than 2.3 per cent. I am talking about across the piece. It is £13.2 billion across the whole area of your responsibility and that increases to 0.6 per cent. Clarify, because you are right that there is a distinction between the board uplifts and then some transfers into their baselines in next year. The point that we have tried to make in the budget document is that there is a contribution towards inflationary pressures and there is also investment in reform next year. What we could have done is put all the money just into board uplifts for inflationary pressures. We have tried to target some of it for investment primary care, mental health and so on. We thought that it was appropriate that we recognised both of them. That is why we talk about investment of £128 million in year. If you take that into account, then it is more than an inflationary increase. Because that money is money that the boards will get in year but it is directed through a change fund in order to make sure that the direction of travel is an investment in community health services. However, it is money that the boards will still receive. In terms of efficiencies, efficiencies would suggest that money has been used more effectively. If I look at NHS Tayside or NHS Lothian, let me take NHS Lothian. 70 per cent of its targets are being missed and it is reported in its recent board paper. 70 per cent. Do you think that the efficiencies that are being made there are effective? Well, I certainly understand that efficiency savings can be challenging for boards to deliver, but if we are going to shift the balance of care and if we are going to make sure that services are funded within the community, then we need to ensure that services are delivered in the most efficient way. However, if you take, for example, Lothian's Enrack uplift for 2017-18, it is getting the lion's share of the £50 million. It is £19.2 million, so Lothian will get a 3 per cent uplift. Although it is still tough for boards, I think this is a fair settlement for the NHS that will require not just and has a significant investment, but it will require reform alongside that. We have delivered what we committed to deliver in our manifesto, which was the £500 million above inflation commitment. That was by far the highest level of commitment of any of the manifestos, and that is what we will deliver. However, it will require efficiency savings from boards. My final point before I move on. If they are getting, as you say, more money and they are becoming more efficient, yet they are missing more and more of their performance targets and criteria, what do you say to patients and staff, for example Lothian, who are being told that more money is going in and that they are all efficiencies and yet the services that they provide appear to be getting worse? We laid out our funding commitments to the NHS in our manifesto and were elected on that during the election. It was £30 million more than, for example, the commitments of parties to inflation-only increases. If we had gone down that line, there would have been less money in the NHS, but, of course, the performance targets of the NHS are tough. There is more demand on our services, which is why, of course, we need to make sure that every penny and every pound that goes into our health and social care services is delivered as efficiently as possible. Yesterday, I laid out a very clear delivery plan of how we would make sure that much of that resource goes to the front line as possible. We need to make sure that what we measure in terms of outcomes for patients are the right measurements, which is why the work that Harry Burns is undertaking is so important. Despite all that, in some of those targets, as you have said, have been missed, the performance of the NHS is still a very good performance, delivering some of the lowest waiting times that we have seen in a long time. I think that what I would say to the public and patients is that the NHS is still delivering a very, very good service, but, in order to make sure that it continues to do so, given the increasing demands of an ageing population, we need to reform the way that services are delivered. That is what the delivery plan that I published yesterday lays out. Good morning, Cabinet Secretary, and good morning to the rest of the panel. I would like to pick up on something that I have discussed with you previously, which is specifically funding to drug and alcohol partnerships. We know that, in the last Scottish budget, those services received a cut of up to 22 per cent, and in my region of Lothian, in Edinburgh City, that equates to a £1.3 million year-on-year cut. I understand that the Scottish Government has asked that the local health boards deliver the services up to the standard that they did before and find money to displace to make that happen, but, as I have just said in the circumstance of Lothian, that is not happening. We know that that is also not happening in Glasgow, where, since that cut happened, we have already started to see an HIV outbreak among intravenous drug users. I wonder if the Cabinet Secretary can walk us through any particular aspects of the budget that mitigate that, which put money back into drug and alcohol partnerships and what the future prognosis for those services looks like? First of all, it is important to say that, as I have said before, the most important thing here is what is delivered in terms of outcomes for those who require access to alcohol and drug services, and the performance around the waiting time standards that we have just been talking about on alcohol and drug waiting times and access to treatment is very good. It is important that boards maintain that level. However, with regard to Lothian in particular—I know that this is an issue that you have raised consistently—my previous answer on NHS Lothian's allocation in 2017 contains £19.2 million of enrack uplift. That is, by far, the highest level in the enrack allocation of £50 million. What we are intending to do is to discuss with boards, particularly those boards that are going to be gaining a significant investment in enrack that they did not necessarily expect to receive, is to discuss with boards what that resource should be spent on. Our intention with Lothian would be to include in that discussion around ADP funding to make sure that it is adequate to deliver the outcomes that are required at the level that we could come to some agreement on. I would be happy to keep you informed about that, but there will be other elements as well in the agreement around the LDP that we would want to see Lothian improve on, particularly some of the performance measures that the convener mentioned earlier on. However, that is a significant additional fund that is available to Lothian that we think is part of which we would like to discuss with them around alcohol and drug funding. Thank you for that. My contention would be that, while outcomes still look pretty good, we are only measuring them for the spending that we were doing before that cut came in and took hold. As I mentioned, with an HIV outbreak in Glasgow and other things happening in other parts of the country where ADP funding has reduced, we may see that that is problematic, but I am grateful to the Cabinet Secretary for those Assurances that I look forward to hearing more information about that. Can I just ask briefly if I may convener about mental health funding in specifics within that? Obviously, I think that everybody around this table would welcome the increase in funding towards mental health. Can you specifically cover two areas, which is in terms of child and adolescent mental health services? What sort of percentage of that spend will be directed at child and adolescent mental health services, particularly in reducing waiting times and access to tier 3 heads? I have recently been quoting the media talking about the need for mental health first aid and looking at upskilling our workforce in mental health first aid. Can you possibly cover those two issues? A lot of the detail of what the priorities for mental health spend will of course be part of the strategy going forward, and I know that there has been engagement around that by Morine Watt, the mental health minister. We are always open to suggestions around how we could deliver and develop new services within the community. You will have seen at the weekend, Morine Watt, was talking about the £10 million for primary care services, for mental health services within primary care. Importantly, the delivery plan that I announced yesterday focused very much on that shift in spend to community health services, including primary care, mental health and social care. Within all that, there is scope to develop many innovative services for mental health, whether that is within schools, primary care and, indeed, to improve some of the services within our emergency services that are responding to people who are in crisis. It is a draft budget, and there is further scope to discuss some of the detail. We have set out a number of priority areas for mental health spend. It is quite a substantial additional spend over the course of this Parliament. However, if there are specific issues, detail and suggestions around some of that spend, those discussions can be had in further detail. Thank you, convener. Thank you very much, cabinet secretary, for joining us this morning. I think that your Government had anticipated that by 2016-17 no board would be below enrack parity level. I appreciate your comments regarding the increase, particularly in Lothian, but it is still below parity as are seven other health boards. I would like to ask if the Government is still committed to enrack parity and what the timescale is for achieving that, if you are. As I said in my opening remarks, all boards in 2017-18 will be within 1 per cent of parity. That funding will mean that, since 2012-13, an additional £884 million has been committed over a six-year period to those boards below the enrack parity levels. That is a significant investment and that will continue to make sure that boards are kept at least within 1 per cent of parity. The investment, the £50 million in 2017, will make a big difference, particularly to those boards, such as NHS Lothian, which has had a number of challenges. Christine Grahame, do you want to add in? A couple of things, if I could. One is that what we are keen to see is that that additional funding gets used for investment. If I look at NHS Grampian over the past few years, it has taken additional enrack funding and treated it as not just going to the bottom line for the pressures, but they have invested it in services. That is what we would like to see across the boards, that they really get something that you can see that helps to make services more sustainable. A couple of other things. One is that, in making those decisions about going for a lower level of uplift for all boards on a cumulative basis, we usually start to see the impact of that. When we talk about the in-year funding, the £128 million that goes to boards, the more that we start to shift that money in a way that fits with the enrack parity, if you understand what we are talking about. Rather than giving it out on funding and on shares, we start to make bigger in rows into that shift. With every element of additional funding that goes to boards, we always look at it to see whether we can continue to help to move closer towards that parity. The final thing that I would say is that we have also said to boards that we would give them a three-year forecast to give more certainty about what the enrack position would look like for the next few years. As part of finalising the budget, we will give all boards the forecast position of their shares for the next three years, based on current population trends. If you look at that, you will see, for instance, that an area like Lothian population trends continue to forecast an upward rise of growth of about half a per cent every year, so we would expect to continue to put more money in over the next few years. However, getting to 1 per cent for all boards in this way is the closest we have been since that commitment was made. On another issue, there has been a significant cut to the sports budget, 7 per cent in cash terms and 8.3 in real terms, which is obviously of great concern to many governing bodies and to people delivering sports in our communities. We are aware that all the international research suggests that a major global games is no guarantee that we will see a significant increase in people participating, but cuts of that scale certainly will not help. I wonder whether the cabinet secretary has been in discussion with the governing bodies and others about the impact that this will have. Well, certainly, Eileen Campbell, as the Minister for Public Health and Sport, has been. It is a tough settlement. We would expect Sports Scotland to focus on the delivery of grass-roots sport and community sport in terms of prioritisation. The commitment to increase community sports hubs is important. We also need to see some of the other investments in early years and public health measures as being also important. The new diet and obesity strategy, the investment through education and PE, the active schools network, all of these things, I think that we would want to make sure that we are prioritised. I think that also there are other parts of government that contribute to sport, for major sporting events, through events in Scotland, for example. We have also just seen today a pretty significant announcement around tennis investment next year, a partnership between the Law and Tennis Association and Sports Scotland, a £15 million investment. It is a tough settlement. We will continue to talk to Sports Scotland and the governing bodies. I am aware that there is also lottery pressures, which are obviously additional. I am happy to have further discussions, but we would expect them to, within that tough settlement, prioritise grass-roots and community sport. I think that it is fair to say that those groups who lobby for greater investment in active travel infrastructure are disappointed to say the least that there has been an increase in the trunk roads budget, which is four times the size of the entire active travel budget. We heard from Ian Finlay from Paths for All in our session on obesity that physical inactivity is costing the NHS, costing the country £94 million a year. If climate change and health are cross-cutting government priorities, is there an opportunity for you to speak with the transport minister and suggest that this is revised in an upward direction before we come to vote on any budget? What is fair to say is that we need to make sure that across government—I have had discussions with the previous transport minister and the current transport minister and other ministers across government—how we better co-ordinate our work to be more cohesive and coherent around tackling some of the big issues of the day, such as obesity. Government is always about balance and about making sure that we are also investing in some of our infrastructure that needs investment. Those things are always about striking the right balance, but I am happy to continue those discussions around active travel. There are perhaps opportunities as we revise our obesity strategy next year to look at that in more detail and how we can encourage people into public transport, walking and cycling. Of course, there has been investment in our cycle infrastructure. We have investment of £39.2 million per year in active travel, which is not insignificant, but it is a draft budget and I am happy to continue to have those discussions. I would like to emphasise the point that that £39.2 million has not increased at all, but the Trunks roads budget has increased four times that of the entire active travel budget, so I would be grateful for any conversations that you might have. Briefly, what is the thought process behind sport getting such a significant cut? What is the logic of that? It is a tough budget in that we need to make sure that we are able to prioritise the areas of investment that I have made clear around community health services. We have prioritised investment around early years around making sure that some of the preventive work that we do within our health services is prioritised. Within sport, we have said that we want priority given to grass routes and the active schools element. That is about having to set a tough set of priorities. It is a prioritisation. Good morning, cabinet secretary and panel. I would like to ask about the £500 million additional funding to primary care. Just to make one thing clear at the start, is your commitment one that you will invest £500 million additionally each year by 2021? Have I got that right? It is £500 million over the course of this Parliament into primary care and that will deliver an 11 per cent share of the budget. This next year, the budget into primary care is going to £72 million. The breakdown of that includes the GP contractual uplift and population growth, but it also includes investment in the new models of primary care. That is about delivering the new vision of primary care that we want to see, which is the multi-disciplinary team working. It is £500 million over the course of the Parliament. In terms of the £72 million that you have just referred to, are you able to give any breakdown as to primary care general practice at this stage? The team has been working on prioritisation of that investment. It is not yet finalised, but we will be happy to share what is within it, because there are quite a lot of different components. There are certain areas that are part of GP investment, but there is also investment in digital technologies and implementation of the out-of-hours review. There is quite a lot within it, as well as funding for resources on the ground in partnerships to try out some of the new models of care. A whole raft of things make up that £72 million. Once we have that in a slightly more advanced stage, it is not very near into the new year to be able to share that with you. I am also happy to share with you where we are in terms of that shift in what we are looking at for next year. I think that it is important to distinguish between the funding that goes in and the expenditure on the ground. We are doing quite a lot of work to try to understand how we would see those flows and what kind of reporting we will have against them, so anything like that that you would like to see, you would be happy to give you more information on. I would very much like that information. I am sure that the committee has used the phrase by the cabinet secretary last week, Derek Mackay, on an improvement plan. Is that just a general ambition to improve general practice and primary care, or is there a concrete improvement plan? The changes to primary care are a critical part of the delivery plan that we have published yesterday. We have talked for quite a few months now about the profession, the BMA, the negotiation of the new contract and what that is going to deliver, but also the wider investment in primary care. It is about ensuring that we build up the workforce around the multidisciplinary team. Of course, there will be more of that in the workforce plan in the spring. We are delivering not just a funding plan but a reform plan as well, which is why the new model of primary care is so important. There are also short-term measures and funding to address things such as recruitment and retention, supporting clusters. There are elements of funding that are very much around the here and now, and there are elements of funding that are more about transformation. There are many questions that can ask you about the budget, but there are two particular items that I have always been interested in. One is that, as you know, I have continually pressed the case of patients who have been contaminated with contaminated blood products. I notice that the budget has not changed any. Can you tell me what position we are at? You gave me an answer at the end of the last session of the last session of the Parliament on the payment programme for patients with contaminated blood. Can you tell me where we are at the moment, as it is still being held back by the UK Government? The latest progress is being made on making sure that we have some interim arrangements to be able to make additional payments to those affected. My officials are at quite an advanced stage of discussions with the funds down south and the Department of Health officials to get that money into the hands of people as quickly as possible. The second stand of this is setting up of the Scottish scheme. I am confident that we will have that up and running within 17-18 to be able to deliver the more comprehensive package of support to those affected. I think that, in total, the package is about £20 million. It is a significant investment, but what is important is that the money gets into the hands of those affected. A lot of work being done to try and do that as quickly as possible. We have been working with stakeholders as well around what the new Scottish scheme will look like and making sure that there is patient involvement in that. I am happy to keep you posted as we take those things back. Basically, again, there is no effect to this extra money. The sooner it is paid out the better, I have to say to you that it will be fresh in regard to that matter, but there will be no effect on local budgets and local NHS. The second question is that we went through joint boards, integrated joint boards. We identified that there would be savings of £140 million, which I do not think that we are going to see. The concern that I had was that some joint boards actually still hadn't made up their budgets by October and November of this year. We are now predicting that they will be able to do it next year. Do we have total confidence that integrated boards are doing that? What monitoring will they have on their budgets? Do we have someone checking on integrated boards to ensure that they are meeting their responsibilities? I will let Christine answer in a bit more detail in a minute, but we have tried to make improvements around the budget-setting process, because you are right that there were certainly some challenges with that. The statutory guidance requires three-year budgets with a review of years 2 and 3 carried out on an annual basis. Boards and councils are adjusting their budget-setting processes to fit with that cycle. That entails a greater adjustment from health boards in making estimates for medium-term assumptions and associated risks. A lot of work is going on with directors of finance. Christine, do you have more of the detail on that? We expect those timing issues to have been year one transitional issues, and I am certainly assured from conversations with the integration authority chief officer, chief finance officers, that they feel in a clearer position in terms of their plans for next year. Even the fact that, in getting to agreement on the draft budget, we are much more joined up between the discussions that we have had between the health, local government and integration authorities. Those are reasons for people being unclear about the settlement. I think that we can start to see real improvements in that. Clearly, there will still be the work with integration authorities about how they deliver their plans, but I would still have an expectation that the integration authorities, as with all other public bodies, should be in a position for the beginning of the year to have much greater clarity on their overall levels of funding and the plans that they need to operate within that. Just lastly, on that same subject, convener, are we going to ensure that we go through integrated joint wars to ensure that they are given a value for money? Through the minister of strategic group, I am chairing a meeting tomorrow. The remit of that group has changed to give a bit of a sharper focus to how we oversee performance and how we support partnerships to develop best practice, how we share best practice, how we support them through improvement teams to make the changes that need to be made if they are not delivering where they should be, or collectively, with local government and third sector partners. Everybody sits around that table jointly responsible to make sure that we deliver and they deliver what we need to see delivered. If you look at, for example, on delayed discharge, as I have said before, if all partnerships were delivering at the rate of the top 25 per cent, which are a mix of partnerships—some rural, some urban—we would be able to halve the numbers of delay just by doing that. There are things that we know work, and we are keen to help partnerships to make those changes. The role of the minister of strategic group in having oversight and support is hopefully going to make a difference. To add to that, the £8 billion that is within the remit of the integration authorities is integral to the sustainability and value programme for the NHS. Savings programmes and efficiencies in areas such as prescribing are wholly dependent on the integration authorities being part of the solution for that. We see the line between bodies being much more fluid, so that we are all working together on that programme overall. However, I think that I would say how do we get the best value for the £8 billion, rather than looking at one subset within it? We really start to see some differences and some really good examples of changes in ways of working coming through integration authorities and the way in which they are treating people in their own homes in particular. We really need to see that accelerate through next year, and that is what our focus will be on. In the committee's report, we said that we wanted to see some action on aligning of budgets, but the response was that there was your view that there was no need to issue any new guidance on that. Are you confident that we will not see that this time round? On aligning of budgets, they are entirely aligned, I would say, and that is why, in looking at the funding letters that went out last week with the budget, we were completely consistent in the message to all bodies. Those types of reasons are not there any more, so the only reason that I can see in which we would not have a signed-off budget at the start of the year is if there is still some work to do on understanding some of the savings programmes that would need to be put in place. However, there should be no process reason in relation to not getting information about budgets at the same time if that answers your question. We will watch that with interest. Last year, NHS Scotland spent £248 million on locum doctors and nurses. That was a £41 million increase on the previous year. What does the cabinet secretary believe that will be in 1819, and will it increase? Our aim would be to reduce that spend, and part of the national programme that Christine and her team are involved in with boards is very much about driving down those agency costs. If you look at one of the boards that has been delivering a significant reduction in agency spend because they had one of the highest is NHS Tayside, we would expect that the best practice of how to do that is shared across boards. The chief nursing officer Fiona McQueen has been working with boards around getting the balance of filling some of those substantive posts. She has been working with directors of nursing in boards to look at how that can be done in a helpful and meaningful way. Christine, you can say a bit more about the national programme, but this is a really important priority for driving down. We have given some direction to boards this year in the draft budget and looking at how the money is used next year in areas that we expect to see improvements and spend on agencies and locums as one of those areas. Overall, what we are saying is that we expect to see a minimum 25 per cent reduction next year. I think that there are two aspects to that. One is about where you need to use agencies that you do in the most effective way. Ultimately, the benefit comes from managing your need for staffing provision and to look at alternative ways. That is why things such as introducing regional bank for medical staff are critical that they are in place. What we are seeing is that we are not getting that reduction in locum spend until things like that are in place as a substitute. I think that we are much further on in that and I really expect to see some reductions. It will probably vary across the country because it will be about local circumstances and individual boards, but we really do expect that 25 per cent to be a realistic target for next year. My second point was regarding the use of the private and independent sector. How much has been spent this year on patients having to be treated in the private and independent sector? What are the projections for future years? Will that also be increasing? It is actually reduced this year and is reducing. When we launched the £200 million plan for elective centre development, which is over the course of this Parliament, we were explicit that one of the reasons for doing that was to further reduce spend on the private and independent sector by having that elective capacity there to meet the needs of the population, particularly the growing elderly population of hips, knees, cataracts and so on and so forth. The use of the private and independent sector has been used by some boards more than others but we would only ever expect it to be used at the margins. There is never a replacement for capacity in the NHS, but we recognise the need for additional elective capacity. That is why we are going to have additional five centres in addition to the Golden Jubilee. I would anticipate less spend on the private and independent sector. I do not have the detail yet until we see the plans from the boards. We have just given them a settlement. We will start to see that in January and February next year. We also know that there is a real theatre improvement programme going on just now to look at how you can increase your number of procedures in a day in a theatre. Things like that can have an impact on your need to use additional capacity. That is what some of the work through the national clinical strategy is starting to make inroads in. There are some really good improvements in areas such as NHS Lothian. A lot of looking at practice in areas such as the national waiting time centre, where the number of operations in a session is higher in some particular specialties. It is those types of things that will see an overall reduction in the independent sector. In your opening statement, you included £107 million for social care and the overall figure that you gave for health spending. Can you confirm that the £107 million is for the health budget and not for local government budget? The £107 million is being transferred through the health budget into the integrated authorities, which is what we have done with the £250 million. It has been done on the same basis. Given that we are, we now have an integrated system. That is clearly about moving out of silos and the £107 million is transferring through the health budget into the integrated authorities. In the budget document, in your statement earlier, you included £107 million in the overall figure for health, the health budget. Can you explain then why, if you look at the budget document published by the Government page 101, that funding for health and social care is also included in local government's budget and for the first time under the column of other sources of support? That did not happen last year, so why is it happening this year? Does that not surely lead to accusations of double counting? No, I do not think that there is double counting. We have been clear in our statements that the £107 million, in the same way as the £250 million, is allocated to the health budget and then transferring it into the new integrated authorities. I do not think that that could be clear. What we are trying to do is make it as transparent as possible. The language is very clear. The issue with integration authorities is that they do not get a budget as part of this budget settlement. Their budget comes through health and local government. We felt that it was not really about whether the money sits within the health part of the portfolio or local government, that the funds are transferring to the integration authorities. That is what we are trying to be really clear on, that funding transfers to integration authorities. The reflection in local government is not adding to the value of the settlement. It is showing as an other source of funding because it flows through from health. I might just be a bit pedantic, but it is only included once and the overall numbers are included in the health settlement. It is not included in local government, but it is part of the settlement. It is shown below the line as a source of additional income that is flowing through from health, but it is absolutely only counted once in our overall financial settlement on the budget. You certainly confirmed to me that it is contained within the health budget and therefore it cannot also be contained in local government budgets as well. Within the world of integration, which is surely a good thing that we are seeing that as one system instead of two systems, I would have thought. Obviously, the money cannot be spent twice so that the budget should be given. I do not know that anyone is claiming that it is. I will beg to differ, but if we look at the actual £107 million, it is largely ring fence for specific purposes, in particular the living wage. Can you confirm that you are happy that the funding that is being provided this year for the living wage in all IGB areas is going to be sufficient to cover the full cost of living wage? I will welcome the fact that, for example, that previous bizarre assumptions about 25 per cent of the cost being provided by the provider himself is not going to move, so can you confirm that that funding will fully cover the full cost of the living wage? Can you also explain specifically what the £10 million is for sleep overshifts? What exactly will that cover? Obviously, it would not cover the full living wage for a sleep over shift, so what will the £10 million actually cover? The £80 million to support the continued delivery of the living wage is important. That enables the increased rate of £8.45 per hour to be paid and to care workers supporting adults in care homes and care at home housing support settings. It should now include where it has not already had adult daycare workers and personal assistance through arrangements made where care is provided. The figure of £80 million and the £10 million that is being identified for sleep overshifts has been based on negotiation and looking at what the cost is with local government and third sector providers. There has been a huge amount of work going in to make sure that we can get that as accurately estimated as possible, but we will continue to work with COSLA and third sector providers as we take that through the year to make sure that that can be delivered. I think that it is a substantial investment in making sure that, I think, 40,000 workers will continue to receive the living wage and will deal with the issue of sleepovers, which I know has been raised by yourself and others within this committee. What I am not clear about is what exactly will the £10 million cover. If you look at the number of sleepovershifts, it will not cover the full cost of paying somebody, for example the living wage for a sleepover shift, so I am not sure how that £10 million comes about. What will it actually specifically cover? It was agreed that all waking hours would be paid at the living wage with sleepover hours being paid at an average for all hours of the national living wage over the week. It is being agreed that this position remain as part of the offer for 2017-18, and that is going to allow time for reform to take place and more work to be done between ourselves, COSLA and the third sector on making sure that we can continue to make sure that that is delivered. I think that where there are concerns has been around ensuring that those who are vulnerable receive sleepover support, and that that continues to be the case. That is the most important thing as we take forward those discussions. Work in progress, I would say. Can you explain that part again? I certainly miss that you have skated over quickly. What does that in practical terms mean for staff doing sleepovers? You are saying that it is only covering waking hours? It is part of a negotiation that is still going forward, I think. At the moment, what is the position as you describe it? What is this? It has been agreed that all waking hours will be paid at the living wage with sleepover hours being paid at an average for all hours over the week. It is basically averaging out the hours over the week. It has been agreed that that position remains part of the offer for 2017-18 to allow time for further discussions to take place with providers and with COSLA. I am happy to provide more detail on that, because it is work in progress. I am no clearer. That is maybe just me. I would not surprise me if it was. It is complex and detailed, and you will appreciate that there are on-going discussions with the sector and with local government about trying to make sure that we give a fair position to those who are working in a sleepover setting. It might be helpful if you were to provide that and provide an example of Mr or Mrs Smith and the hours and how it would work for them. I think that that would be helpful, because what you have described is the current situation around the HMRC rules, but it is how we move forward. Obviously, most of the £107 million that you have described is ring-fenced, £87 million, £80 million for the living wage, £7 million for changes in care charges. It is largely ring-fenced. Can you explain why the Cabinet Secretary for Finance wrote to local government leaders last week to sanction an £80 million cut in the contribution from local government to IJBs? That will more than cancel out any additional funding that has been provided in the £107 million, given the fact that most of it is ring-fenced. First of all, it is important to look at the global amount that has gone into integration. The £250 million last year in 1617 continues to be provided into integration authorities. In addition, in 1718, there is another £107 million, albeit that the focus on that has been to deliver the living wage, I think quite rightly. Within integration authorities, there will need to be efficiency savings and reforms around how those integrated authorities work to make sure that all of the resources that they are getting is delivering to the front lines. Although more money is going into integrated authorities, they will require, as health boards, to change some of the way that they operate. I think that it is important through the delivery plan that we published yesterday to recognise that investment reform is on the other side of the coin, and that is what we will be working with integrated authorities to deliver. There are a couple of things that I just wanted to touch on. The first one was just to clarify, right back at the start, when we spoke about the overall picture and the numbers. In cash terms, the overall budget is up to £267 million, which is 2.1 per cent. In real terms, which means that over and above inflation, it is up to 0.6 per cent, which is £79 million. If I am reading that right, the 0.6 per cent increase is after inflation has been taken into account. The £79 million is the first step to the manifesto commitment of increasing health spend budget by £500 million over a lifetime of the Parliament. That is correct. I think that earlier on, there was some confusion about the 0.6 per cent, and I was trying to say that that was in cash terms, not in real terms, but in real terms. That is clear. That is in general inflation rates, not health inflation rates. That is 2.3 per cent versus 2.1 per cent. As you also said correctly at the end of the day, what this is all about is outcomes. It does not really matter how much money we put in or do not put in, it is what is delivered from the health service and from the process as a result of that. I really just want to drill down a wee bit in a couple of areas. One round about how we are measuring what boards are delivering, given that there is a target review in place, given that there is a national performance framework, given that there are outcome measures, there are a number of different frameworks for measuring things. How we are drilling down to measure boards and taking best practice across boards, and how we are dealing or dealing with boards that are not delivering what they should be doing, and what is the efficiency process, and by that I mean how we are identifying best practice, how we are getting that transferred across the piece. Again, being clear efficiency in my mind means delivering more for the same or less, which is different from that. Talking about how we identify areas where we can deliver more for the same money or less money across the piece. There are clear performance management arrangements for the NHS that Christine and others within the Scottish Government will support and boards to make sure that they deliver, whether it is on their financial performance or on their patient-facing performance targets. Each board will develop their local delivery plan, which will set out what they are going to deliver for the resources that they get. That gives visibility to the priorities. We would expect them very much to reflect what was published yesterday in the delivery plan for the NHS and care services, demonstrating a shift in the balance of care, making sure that they are investing in the preventive measures and all the things that we know will make a difference in those community health services. There are the opportunities, as we laid out yesterday, to look at some of the support functions and how, through regionalisation and making sure that boards are working together across regions, whether that is on clinical networks and providing more sustainability to rotas and so on, or whether it is support functions that support our NHS, that we can deliver those on a more efficient basis. Christine and her team are working with boards on some of the specific detail around that to make sure that what we know is working, and we have a list of good examples of what boards are doing in some parts of the country, that that is shared. We take a once-for-Scotland approach, which is, if it is working somewhere well and driving efficiency and making sure that money can then be invested in patient care, then we would expect boards to do that everywhere. Okay, thanks. At the final point, we were following up on what Alison Johnstone talked about. Clearly, it is a big interconnected thing, and there is other stuff happening in other Cabinet Secretary's budget areas that will have an impact on health, active travels and all those things, but there could be other areas, such as housing that will improve health outcomes, et cetera, et cetera, et cetera. Are there other areas in which you are having conversations or looking at other spend areas outside your remat and having the conversation around about if we spend more on that, then it is going to save money on the health budget in the medium of long term? It is important that we have those conversations with some real data behind them if we are moving forward seriously on the preventative agenda. Yes, we are. If you look at some of the education spend on the attainment challenge, for example, a lot of it is around ensuring that children get the best start in life, through education and childcare support, that we are avoiding people ending up using NHS services when, if we can, through early intervention, early years intervention, things like family nurse partnership as well, health visitor investment, all of those things align to try to prevent ill health in later life, so, yes, it is very much so. We were fortunate enough to hear some evidence a few weeks ago from Sir Harry Burns about the target review that he is doing, and he spoke there about some of the concerns that there were about targets skewing performance and being a tick box exercise. I wonder if he could tell us how you anticipate that draft budget will shift the focus on the improvement agenda, and if there is any specific funding for programmes such as the Scottish patient safety programme? The work of the Scottish patient safety programme continues and is very important in making sure that our services are as safe as they can be, and the focus has moved from not just acute care but looking at other parts of the system and community health services as well, so that work and investment continues. The target review is obviously on-going, and Harry Burns is talking to a number of important stakeholders who will have a view, whether it is the patient view or indeed the staff view. I think that where there is consensus is that we should be focusing more on outcomes. His work is on-going, so he is getting on with that. I will await his report in the spring. I am sure that he will help to make sure that what we are measuring is the right things that reflect more the integrated system that we are now working in, and that we can ensure that our resources are delivering in the best way possible. It is an important part of the changes that we need to make. I know that time is short, so when you are responding to us with some of the written information, you could also address the issue of the NPD situation, where money has gone from off balance sheet to on balance sheet and what the implications of that are for capital spending within the NHS. That would be very helpful as well. That is the end of our meeting today, and I would like to close the meeting and wish every day a very healthy and sporting new year. Have a good festive season.