 I welcome everybody to the 13th meeting of the Public Audit Committee in 2023. We've received apologies this morning from both Colin Beattie and Willie Coffey, but I'm delighted to welcome Bill Kidd, who's substituting on the committee today. The first item on the agenda is for members of the committee to consider whether or not to agree to take agenda items 3, 4 and 5 in private. Are we all agreed? We are agreed. The principal item on our agenda is an evidence session on the Audit Scotland report NHS in Scotland 2022, which was a section 23 report. I, just in the interest of transparency, want to refer members to my register of interests, which includes the membership of two trade unions that organise in the national health service. I'm especially pleased this morning to welcome our three witnesses, Caroline Lamb, who's the chief executive of NHS Scotland and the director general of health and social care. Richard McCallum, who's the director of health, finance and governance in the Scottish Government. John Burns, who's the chief operating officer in NHS Scotland. You are all very welcome here this morning. We've got quite a number of questions we would like to put to you, but before we get to those, Caroline Lamb, could I ask you to make a short opening statement? Absolutely, thank you. I welcome this report and indeed the close engagement between Audit Scotland and my team, which is so important. The new First Minister has set out his priorities for this parliamentary session, which included determined focus on the recovery, reform and improvement of NHS and social care services. Audit Scotland's report clearly sets out the challenges that the NHS and social care face as a result of the pandemic and notes that Covid and other respiratory viruses continue to impact on services. Their report highlights our focus on recovery, which has included a successful vaccination drive and a significant reduction in two-year outpatient weights. Ministers have met the commitment to provide over a billion of additional funding for health and social care in 2324, taking the total allocation to over 19 billion. It is for me to ensure that that funding is used effectively to drive the reforms that are needed and to ensure that people receive the treatment that they need as quickly as possible. The First Minister, the Health Secretary and myself understand the importance of reducing hospital occupancy to ease flow and to improve capacity for urgent, unscheduled and planned care. We will do that through increasing capacity in primary, community and social care. NHS 24 on the Scottish Ambulance Service has successfully increased the number of people that they are helping without needing to attend A&E. The report also notes other work that we are doing to increase our capacity to care for people outside hospital. About 97 per cent of discharges take place without any delay, but addressing the remaining 3 per cent that are delayed and their impact on the whole system is of critical importance. We have worked hard with partners in health and social care to understand the actions that improve discharge flow. We will continue to support systems to improve those actions over the coming months. Central to our recovery is, of course, the £1 billion NHS recovery plan. That includes increasing activity through the establishment of national treatment centres, through investment in mobile theatres and diagnostic facilities and through using the centre for sustainable delivery to maximise the impact of the resources that we already have. There are some indicators of success. Scotland's A&E continues to be the best performing in the UK for over seven years. An average of 591 operations were performed each day in February, which is 15 per cent higher than in January. Of course, we all want to go further and faster, but we need to acknowledge the progress that has been made, given the continuing shock resulting from the pandemic. I would like to finish by once again thanking our exceptional health and social care staff. Myself and my colleagues are very happy to take your questions. Thank you very much indeed. Can I just begin by asking whether or not you accept and agree with the findings and recommendations of the Auditor General? Yes, I think that we do accept the findings of the Auditor General and we will want to work with colleagues across health and social care systems to ensure that we take forward some of the recommendations in this report. We accept absolutely that the NHS is in very challenging times and we are all focused on trying to navigate a path through that. Do you accept the point that is made by the Auditor General in paragraph 99 that the wording of new targets is open to interpretation? There is a question mark about whether waiting time targets are properly useful and transparent for people. The report also notes in paragraph 105 that the Office for Statistics Regulation has deliberated that the statistics produced by the Scottish Government on waiting times could be misleading because they are based on median waiting times. Do you accept that criticism? I would say that we are absolutely determined to be transparent and open with the public, with ourselves, Audit Scotland and Audit Scotland do also attend our regular assurance meetings. It is a very complex picture. Planned care, unfortunately, is impacted by the pressures on urgent and unscheduled care. We are working with NHS boards and through national modelling to try and, as we come to later questions, John will say a bit more about the work that we are doing around national and local modelling, particularly for planned care. In terms of the specifics around the online waiting times platform, that was developed in collaboration with Public Health Scotland and NHS 24, with the intention of providing information about typical waits. I am sure that you will appreciate it. It is a very complex picture. It uses statistics that are quality assured and collated by Public Health Scotland. We are continuing to improve that with updates already having been made to provide more information and to link to the official statistics sites. We had an exchange of correspondence just about a year ago. You replied to me on 13 May saying that, at that time, we are committed to being open and transparent about data on waiting times performance. Several months later, an Audit Scotland report comes out, which points out that, not only have you been criticised by the Office for Statistics Regulation because your waiting time target information is not transparent, but you are also criticising a similar vein by the Auditor General. As I have said, convener, we are committed to trying to provide transparent waiting time information whilst recognising that that is a very complex picture. We have worked with Public Health Scotland to provide that information. Public Health Scotland has accepted that criticism and Public Health Scotland is looking at ways in which it can improve that information. We are committed to being able to provide that information in a transparent and open way. When can we expect to see that? I will need to contact Public Health Scotland to get some further information on that and I will commit to getting back to you on that. One of the areas that I identified in the Audit Scotland report is about the delays to the roll-out of the national treatment centres, which we all understand are critical in tackling waiting times, the backlog but also, I suppose, not just addressing the immediate pressures but providing a longer-term route for getting people the treatment that they need. There has been a delay. Can you tell us where we are in the opening of the national treatment centres, some of which I think were meant to open last year and still aren't open? Absolutely. I am sure again that colleagues will understand that, given the issues around building projects during the pandemic, perhaps inevitable that we would see some delays. However, the national treatment centres in both Fife and Highland are now open and the national treatment centres in Fort Valley and the extension to Golden Jubilee are on track for the end of this year. The treatment centres in Fife and Highland are open and are now treating patients. In relation to the rest of the programme, that programme is in different stages around the preparation and proper scrutiny that you would appreciate of business cases and working with NHS Assure to ensure that we are providing the best possible facilities that we can. Clearly there have been issues around cost inflation but those business cases are working through the process. I would say that we are not waiting for those national treatment centres for more and more physical premises to come on train. We are also very focused on what we can do within our existing estate and how we can increase productivity within that existing estate. That has included, as I mentioned in my opening remarks, providing mobile facilities to boards to help them to up their activity. Just to go back to what you said earlier there, you said that the NHS Fort Valley lab at site treatment centre and the expanded one at the Golden Jubilee in Clydebank will be open by the end of the year. Can you give us a definite commitment that by December of 2023 those two centres will be open and receiving patients? Yes, they are on track to be open in December. John Bund, are you confident about that? Yes, we are working very closely with the boards and we are confident that, unless there are any unforeseen circumstances, those projects are on track to be opened by the end of the year. If we take the Golden Jubilee site as an example, if that is open by the end of the year, how does that compare to when you expected it to be open when the construction work was originally procured? I think that we will need to come back to you on that one. Clearly, there has been a number of changes as we have gone through the pandemic, so I will commit to providing that information to the committee. You accept that there has been a delay? Yes. Inevitably there has been a delay, as we have seen with most building projects that have been on site during the pandemic. As a committee, we are used to delays and sometimes they are not as inevitable as you are perhaps suggesting. What does that do to the cost of those projects? Is it going to come in on budget or is it going to be over budget because there is a time delay? Richard, do you want to write our expectations? In terms of the projects that have already been built, we have had an agreed budget through the outline business case. When they are then returned with the final business case and the full business case, we would expect them to be in line with those four business cases because of the infrastructure inflation that we are seeing. There is risk to that and we are seeing that across all our infrastructure programmes at the moment. However, in that final business case, if there are any deviations from that, we would expect to be informed by the project as it moves towards completion. Sorry to labour the point, but what is the budget, for example, for the lab at site? What is the budget, for example, for the Golden Jubilee site? Where does that now sit? I will come back with a detail. I do not want to quote a figure that is not correct on those two sites. We will make sure that, for all the NTCs, you have that breakdown of the initial budget and where that spend is against those programmes. A lot of this morning's discussion will be about the financial pressures that are on the national health service. Caroline Lambie, the accountable officer, is responsible for £19 billion of public money. It is quite important that we get an understanding that you are on top of the pressures that you are facing. I will turn to Craig Hoy, who has some questions to put to you. Good morning, Ms Lambie. I want to refer to the Scottish Fiscal Commission's fiscal sustainability report that came out last month, which raised serious concerns about the future financial pressures on the NHS in Scotland. They identified that that was not just due to an ageing population, but also due to rises in chronic health conditions and the technological advances that are moving forward. What are you and the NHS in Scotland now doing to plan for the future financial pressures to ensure that Scotland's NHS is financially sustainable? Thank you very much for that question. We are clearly very mindful of the pressures that result from the demographics of the ageing population. We also look at the Scottish burden of disease information with a view to looking at the likely demand on health and indeed social care services going forward. We also have our innovation design authority and accelerated adoption programme to look at the innovations that can help a lot of the time to address some of that pressure. As I said in my opening remarks, the investment in NHS Scotland is at an all-time high, sitting at £19 billion. We need to make sure that that money is spent in the best way possible. We do absolutely look in our projections going forward at what that additional burden of disease looks like. A key to that is looking at what we can do, not just within the health and social care portfolio in the Scottish Government but across Government, to improve population health and to address health inequalities, a lot of which are rooted in social inequalities. That is about tackling poverty, poor housing and educational attainment. All those things contribute towards improving population health and therefore helping us to mitigate some of that increasing demand on health care services. I said in my introduction remarks that we are looking at how we can increase capacity in primary community and social care with a view to ensuring that people who are in hospital in the most high end part of our system are there when they really need to be there and can be treated elsewhere and closer to home where that is appropriate. Again, huge work in the run-up to next winter and the run-up to last winter around looking at how we can use NHS 24 and SAS, particularly in the community, to prevent people from being admitted to hospital. I think that the point about innovation is a really good one as well. Yes, there are expensive drugs, expensive innovations coming over the horizon but equally innovation, the use of digital technologies presents us with the opportunity to deliver health care in a different way and deliver health care closer to people. There are lots of good examples where we have been using colon endoscopy as an example as part of our approach to diagnostics where we are rolling out digital dermatology, which again saves people from having to travel into a hospital and also closely diabetes, which helps people to manage their insulin levels in a way that helps to prevent some of that burden. We are looking at this from multiple directions. The Scottish Fiscal Commission estimates that the projected spending on health in Scotland will rise from 30 per cent to 50 per cent within 50 years. Is that a number that you recognise? What sort of conversations would you be having now with ministers about the model of health care in Scotland given that projected shift in spending? I think that a lot of that relates back to what I have just said in my answer. This is about how we can provide services, how we can reduce demand, improve population health, take out some of that pressure on services and that is a cross-government initiative piece of work. That is about what we can do to reduce social inequalities that feed into health inequalities and feed into poor health outcomes for people. That is about reducing demand. It is also about what we can do and there has been huge progress made in some of our out-of-hospital pathways, providing care to people in their own homes rather than in hospital. It is about doing more of that as well and about embracing and adopting innovation. I suspect that over the next few years we are going to see more potential from artificial intelligence than from other areas. Our job is to make sure that we are absolutely focused on what we can do to make sure that we are providing health and social care services in a way that meets the needs of the population but is sustainable in context of overall budgets. That is a long-term sustainability issue. A meeting of NHS board chiefs in September of last year, the draft minutes of that meeting, identified a potential billion-pound black hole in the NHS finances in Scotland. That meeting of NHS bosses said that they were given the green light to almost think the unthinkable about the foundations of the NHS in Scotland, potentially having the wealthy pay for the treatment and a potential two-tier NHS. Is that the kind of discussion that is taking place within NHS Scotland? No, that is not the kind of discussion that is taking place in Scotland. I am on record as having said that I did not give a green light to discussions about challenging the very foundations of NHS Scotland. I meet really regularly with chief executives in NHS Scotland and at least monthly. We talk about where our opportunities are for cost improvement, for delivering services differently, for delivering services in a better way. We talk about that all the time. Absolutely, I would not want anything to be off the table in terms of how we can provide services differently in a way that supports people in a way that they need to be supported, but that is not about challenging the foundations of the way in which NHS Scotland was built. I accept that, but the draft minutes of that meeting say that somebody gave quotes to the green light to present what boards feel reform may look like. Fundamentally, they say that areas that were previously not viable options are now possibilities. What would those viable options be then? Can I be clear about the genesis of those minutes? My understanding was that that was not a meeting that I was present at. My understanding was that that was also not a meeting of NHS chief executives. It was a meeting of maybe one chief executive there and some of what we call functional leads. People who chair the other groups, medical directors, nursing directors, directors of planning, as an example. I was not at the meeting, so I cannot describe the context in which that conversation took place. From my review of the minutes, it looks a little bit like that was a bit of a blue sky thinking. Not with a view to thinking that all the things that they were proposing were reasonable and would be taken forward by the Scottish Government. We know from recent release data that there has been a 73 per cent increase in Scots electing to go private for certain treatments. As NHS chief executive, what would you advise me to do? If I was 80 in pain, immobile, suffering from social isolation as a result of requiring a head replacement, for example, and I had the means to do it, what would you advise me to do now? I would not want anybody to be in pain and suffering. That is not the position that any of us or any of our chief executives want anybody to be in. That is why we have had a focus on trying to reduce the longest waits on our waiting lists and also on trying to support people to live well while they are waiting. I am not advising people on individual choices, but I know that my commitment and our commitment is to do whatever we can in the face of many challenges, particularly around the pressures on urgent and unscheduled care, to maintain that planned care programme and to bring particularly the long waits down as quickly as we possibly can. Do you accept at this point in time when, for example, I have got a correspondence from a constituent who has had to borrow money from their children in order to have a hip operation? That is unacceptable at this point in time. You can particularly understand why people are making the choice to do that in very challenging circumstances. As I have already said, that is not a position that we would want anybody to be in and that is a position that we are working across the system. I think that you could talk to any chief executive across the system and that is something that they are absolutely trying to address in the face of, as I have said, very challenging circumstances and where Covid has not gone away. We still had over a thousand people in our hospitals with Covid in March this year. Turning back to the Audit Scotland report, it identifies that the creation of a national care service requires a significant unknown financial commitment to be met from the Scottish Government's health and social care budget. As you are obviously aware, ministers have determined that they will pause stage 1 off the bill. Does that still have any financial implications for the health and social care budget in Scotland overall in the year of future years? The budget for this year is set and we will work within that budget. There will obviously then be a process in terms of setting the budget for future years. You are quite correct that the timetable for stage 1 of the national care service bill has been extended, and that is very clearly with a view to enabling further consultation and identifying areas where we can reach consensus. At this stage, it is very difficult to say what the financial implications of that will be, but we are committed to producing a revised financial memorandum. In terms of the financial memorandum that accompanied the bill, that identified costs somewhere in the region of £1.3 billion that has been contested. The Auditor General said that he really could not come to a final conclusion as to whether that number was accurate or not. Is there a concern that if the total costs of establishing and operating the national care service, if it does come to fruition, are higher than that, we end up cutting into health expenditure as a result? I think that we need to be clear that the financial memorandum did not contain a commitment to spend that money. That needs to go through business case processes and budgeting processes as well. There is a whole process of scrutiny that we would need to undertake before committing that sort of level of expenditure. As I have said, there is also now a process of taking a moment to do some more engagement with stakeholders, particularly the trade unions and local government, with a view to how we might take that work forward. The implicit in the bill has always been a commitment to co-design with people, and that makes it very difficult to pin down absolute financials. Is there anything that you want to add to that? I suppose just a couple of things. The financial memorandum contained a range of costs, and it was over that five-year period in terms of that set-up. That started from a relatively small sum in 2223, around about £10 million. As indicated by the then Deputy First Minister in 2324, a plan for around £50 million to £60 million of spend. Obviously, with the policy prospectus and what was set out by ministers over the last week or so, we will review that. We will scrutinise the costs in 2324 and the appropriateness of those and the future year projections as well. That is absolutely key. We want to make sure that, while there will undoubtedly be that scrutiny from here and from Audit Scotland, that this has to not just be about additional spend, it is about reform in the system as well. That change and improvement that we know needs to come in social care and that will be the focus of that financial business case that Caroline has mentioned. The Scottish Government's initial commitment was to introduce a national care service in the lifetime of this Parliament. It appears now that it is to legislate for a national care service in the lifetime of this Parliament. Just for clarity, what is the timetable that you have been instructed to work towards? We are currently working towards the extended timetable for stage 1 of the bill and that involves further consultation with stakeholders over the course of the summer, which will then drive the rest of the timetable. Before I pass on, we have talked about financial sustainability within the NHS. You have identified that reform and innovation are obviously going to be critical to the long-term sustainability of the NHS in Scotland. There was clearly that meeting where there was blue skies thinking. We need to engage the public at some stage in relation to what healthcare looks like in Scotland for 5, 10, 15, 25, 50-year timetable. What is your intention in terms of how you engage that conversation with the nation about our national health service? I have a quick follow-up question for you, which is based on the Audit Scotland report. You said at the start that you agreed with the findings and recommendations. One of the headline findings is that the proposed national care service will place a huge strain on the health and social care budget. Do you accept that conclusion? I accept that there is a real requirement for social care reform. I have been really clear that the financial memorandum is not a commitment to spend money. We need to go through budgeting processes and we need to work our way through all of that. Audit Scotland raised some questions about the requirement for social care reform, but there is also a question about how that is tackled going forward in budget. We are working to the budget that we have for the current year and then there will need to be further discussions about what budget is made available to portfolio in future years. It has been questioned by the Auditor General. It was also questioned pretty heavily by the Finance and Public Administration Committee of the Parliament, who told you that you needed to go back and do your sums again and come back with a revised financial memorandum. I cannot remember a time before when that was necessary for a Government department to revise its financial memorandum because it seemed to be so out of sync with what people estimated the costs were going to be. Do you feel quite embarrassed about that? Clearly, we want to get this right. What we do accept is that the bill is framework legislation and therefore there is a huge reliance on co-design in terms of working out the detail of that. That is one of the challenges that we have had in terms of the financial memorandum. As I said earlier, we have a process to go through on that around robust business cases and including that in the preparation of annual budgets. It also depends on the model that is chosen. At the moment, it is envisaged to be a largely commissioning model, whereas at one time we were told that it was going to be the modern-day equivalent of the foundation of the national health service, which is a very different model again from the one that has been put forward so far in the national care service bill. As I said, the timetable for stage 1 has been extended and there will be consultation around what the best approach is going forward. I will turn now to Bill Kidd, who has some questions to put to you. Thank you very much, convener, and welcome to the eight minutes. It's nice to see you here. I'm going to ask some more on financial sustainability. The fact that the Scottish Government's health budget has been informed has increased by £4.4 billion since 2018-19. In 23-24, the Scottish budget total allocation for health and social care is placed at £19.1 billion, which has been brought forward a couple of years from where it was expected to be at £19 billion. However, NHS boards financial plans have shown that 14 of the 14 territorial boards, only three, are expected to break even in 22-23 if their savings targets are met and seven of the eight national NHS boards expected to break even if their savings targets are met. On that basis, can I ask whether the Scottish Government has any update on the number of boards that did break even in 22-23? This is obviously still subject to audit, but we have had the year-end position from all-22 health boards now. 16 of the health boards will meet the financial balance in 22-23. Two further boards will be within 1 per cent of their target outturn. As the Audit Scotland report refers to, that is an agreed parameter that we look to. The further four boards will be further adrift in terms of that outturn position, which is in some ways a similar position to where we were pre-pandemic. There is further follow-up scrutiny now and work with them, particularly looking ahead to their 23-24 plan. That is where we are in terms of the 22-23 outturn. The question of what is in, I think it is appendix 2 of the Audit Scotland report, which shows at that point only three boards being forecasting balance. I think what we see often is boards at the start of the year reflecting a lot of the significant savings that they might have, but not necessarily as those savings start to be developed and delivered. What is forecast at the start of the year, you will see that improvement as we move through the financial year. That is obviously something key for us now as we look ahead to 23-24 and we work with the boards in terms of their plans for the current financial year as well. On the basis that you mentioned Covid-19 and the specific expenditures that were brought about, what are the plans to support NHS boards to continue to reduce whilst monitoring Covid-19? The points that Audit Scotland make up in the key messages around inflation, pay pressures, on-going Covid costs and rising energy costs, I would not disagree with any of those points. That is absolutely true. That is placing a pressure on our health boards that we have not seen in previous years. Specifically on the Covid-19 challenge, for two financial years we had additional Covid consequentials to support those Covid costs. In 22-23, that was stopped. We have had to plan on the basis of not receiving those future Covid consequentials. It has been necessary, as we have budgeted and as we have planned, to think about those Covid costs within the overall NHS budget, the overall £19 billion that you referred to. We need to work with the boards to challenge to scrutinise those specific Covid costs and where possible to bring those down as far as we possibly can, but we need to recognise that a number of those costs will continue. Some of that will need to be managed within the boards' existing resource, the baseline budget that they receive. However, we will provide specific additional funding for certain specific programmes. For example, the vaccinations programme in 23-24, we are planning to allocate £140 million to support the vaccinations programme. Similarly, with the on-going work around test and protect, we are planning to allocate a further £80 million in relation to that. Some of that will need to be managed within that core resource, as other spend is in the NHS, but some of that we will provide specific allocations for as well. That is revision of the current brokerage arrangements with the boards between the Government and the NHS boards. For two years, we paused brokerage arrangements in the context of Covid and the uncertainty around both spend and funding. We saw that as a sensible approach to take. We are moving back into a scenario in which we want to be much clearer up front about budgets at the start of the year and what we expect boards to deliver. Those brokerage arrangements will continue and remain in place. What is key with that is that boards need to have a credible plan. If brokerage is required, there needs to be that credible plan to show how that repayment will be made. That is what we are working with those four boards that I mentioned earlier to deliver on. Does that mean that the Scottish Government still intends to, as was announced, double investment in the health capital maintenance backlog budget over the next five years? Has that been affected by the monies that have had to be allocated for the Covid circumstance? Compared with the revenue budget, the capital budget for health and social care is much smaller. It is around £400 million to £500 million per annum, or it is currently. What we are intending to do, and this remains the commitment over the course of this Parliament, is to see that investment in our backlogs and to increase. Of that, for the £500 million that I mentioned, some of that is for our new builds, the national treatment centres that we have already referred to, but some of that is particularly to support targeting some of our existing estate and the backlog that we have there. Currently, we spend about £150 million to £190 million specifically on that backlog maintenance. What we intend to do, 3 to 25, 26 and 2627, is double that to beyond £300 million. That is taken into account, as I think was mentioned earlier by Mr Hoy, in terms of the ageing population and the extra monies that will have to be generated in order to take up that capacity. I am jumping in here. Caroline might want to say more, but certainly in terms of specifically on the capital and infrastructure, one of the key things that we need to do and reflect is that point about the ageing demographics. The design of hospitals and, indeed, our estates programme more generally needs to look at that wider service plan so that we are planning for the 30-40 years ahead that Mr Hoy mentioned earlier. Can I just take you back to what you said in reply to Bill Kidd's opening questions? Did you suggest that the figure that is in the Audit Scotland report was that only three out of the 14 territorial NHS boards were expected to break even, was just a snapshot at the wrong time? I wouldn't say that it was a snapshot at the wrong time. I think that there is a point in time, though, when boards have developed a plan and the numbers that are reflected in the Audit Scotland report show that, and that will have been from board papers. As the financial year progresses, boards' financial positions tend to improve. Obviously, that is what we have seen in 2022-23. Whilst at that point in time, as you say, only three boards were projecting that balance, we have seen boards' financial position improve over the final six months of the year, which is why at the 22-23 outturn we have seen 16 of the 22 boards in financial balance. The Audit Scotland report came out in February of this year, but just two days ago in this Parliament, the chief executive of NHS Dumfries and Galloway told a health committee of this Parliament that he said, I have worked in the NHS since the 80s, I am finance director by background, I have never seen a position as challenging as this, and he then went on to speak about an existential challenge to our current service models, and he said, he went on to say, I technically can't afford one in ten of my workforce. There is severe pressure on the territorial health boards, and it sounds a bit more like the picture painted by Audit Scotland than it looks like the picture that you have painted for us this morning. I think what Richard has reflected there is the position that boards maybe start off with and the assumptions that they make, and then the work that they do during the course of the year to improve that position. The explanation that Richard has just given you relates to 22-23, the chief executive of NHS Dumfries and Galloway was talking about the position for 23-24, and I have no doubt that many boards are looking at a very challenging position going into 23-24. That said, we would expect, as we did last year, to work with boards through the course of this year. We have a national sustainability and value programme, which Richard might want to say a little bit more about, in terms of how we are working with boards to support all of our NHS boards to identify and deliver savings and efficiencies in order to manage that through to a better position. Just to be clear, I am absolutely not underestimating the scale of the financial challenge and, as I say, the key messages from Audit Scotland I completely agree with in terms of those on-going Covid pressures, the pay inflation that we are seeing and the wider inflation. I think that is absolutely right. We do go into 23-24 with a significant financial challenge that we will need to work through, and that is a reality of those system pressures. Again, as Audit Scotland has said, we are not alone in NHS Scotland in terms of some of those particular pressures that they highlight in those reports. I think that two things I would say specifically on the point that you raised about Dumfries and Galloway and, indeed, where we are at the start of the year. Dumfries and Galloway do have particular challenges, so I mentioned those four boards that are not in financial balance at the year end. Dumfries and Galloway is one of those, so one of the things that we are doing at the moment is working very closely with Dumfries and Galloway around review of their outturn position and the next steps in terms of 23-24. There are specific challenges in that health board. The second thing that I would say is that Caroline touched on the sustainability and value programme. That is absolutely right. There are a number of things in relation to our system improvements and around our efficiency programme where we can go further and we will need to go further, whether that is in relation to our procurement practices. Some of our work around agency spend and medical locums, which we are working with the health boards on as well. The final dimension is that we have settled or are settling the pay awards. That is still an on-going position in England at the moment. There is a question about consequentials and whether they may come through or not. I think that that is presenting some challenges. That is understandable in some ways, but the sooner we get some clarity about that position, that will help as well in terms of potential additional consequentials, which that position is still to be clarified on as well. We will watch that with interest. You have used the word challenging a few times. For the record, it is worth noting that the word that is used by the Auditor General is that the financial position of the NHS in Scotland is concerning. There is a suggestion in there that things are not as they should be and that there are potential consequences for the kind of treatment that people can expect to get. I turn to what I suppose is at the heart of many of the questions that we are asking you this morning. How long the Scottish Government thinks it will take to clear the current backlog and fully recover healthcare services to a pre-pandemic level? I will maybe come to John for some detail around that. We have been engaged now for some time in planning and scenario planning, because, as I explained earlier, particularly when we go through the winter months or when—it does not have to be the winter months—where we have seen peaks in Covid and we have surges in our hospital sector, that does impact on planned care as well. We are looking at planning both at a Scotland level but also working with NHS boards to convert that into local plans and to look to see what more we can deliver out of the system in terms of productivity game, mobile units that I talked about earlier and others. John, do you want to say a bit more about that? Yes, thank you. As has been said, we are working very closely with all of the health boards across Scotland to do a number of things. First, to make sure that we are maximising the improvement opportunities that have been identified. Whether that is colon capsule endoscopy, whether it is cytos sponge, looking also at some improvements that we can make to outpatients in terms of patient initiative review or ensuring that we have good referral triage at referral point to ensure patients are treated in the right pathway. All that work is an important part of the improvements, and we have already seen the positive impact from that work in terms of capacity. Other areas that we are focused on—again, there are good examples—of maximising our day surgery capacity but also looking to extend and enhance 23-hour surgery where a patient will stay in overnight but avoids a long inpatient stay. We are seeing more surgical pathways being able to be delivered in that shorter stay. That brings new capacity by freeing up main theatres. The other thing that we are seeing is that, as treatments change, we are able to do some minor treatments using nurse practitioners. Again, that is bringing a capacity that we did not have previously. A number of improvement initiatives that we are progressing. We are also working with boards to ensure that we are supporting and protecting their work in planned care. That is a challenge for boards. Of course, they are having to balance all of the demands of unscheduled care and planned care. However, we recognise the importance of ensuring that there is a level of protected capacity for planned care so that we continue to make the progress that we have seen in recent months in terms of increasing the number of patients that are being treated. Of course, the NTCs in reference has been made to those excellent facilities and we will be working to ensure that those are maximised. Again, having a protected elective capacity where it is not or does not have the potential for being disrupted by emergency and unscheduled care is an important facility in terms of that maximisation. Our national resource is not just local, so we are working with boards to make sure that we can allocate appropriately and effectively and as far away as possible those facilities. Patients are willing to travel. We hear that they will travel for care and we will support that. The other areas that we are looking at in terms of looking forward, we are working as you would expect this year on our 23-24 delivery plans for planned care to ensure that these improvements are being maximised. We are also refreshing and reviewing our modelling, as has been said. These have been challenging and difficult times in managing through Covid and coming through. Everyone recognises the importance now in doing all that we can to recover and to recover forward. As part of that, we are looking at our modelling for planned care, recognising those improvements that I have said, looking at the NTCs and then looking at what multi-year delivery would be. This is not going to be addressed in just a couple of years, so we need to be clear. We need to be ambitious in terms of the delivery, because we recognise, as has been said earlier, that there are people on waiting lists who are needing to receive that treatment. I know that clinical teams across the country are determined to do all that they can to make sure that we can do that. We are in the process of working through those multi-year delivery plans and that will inform our next steps, but underpinned by maximising productive opportunity. Working with our clinical staff and clinicians in terms of how best to do this and making sure that we are maximising and delivering on the improvements that will see us use the existing capacity as effectively as possible. Obviously, Mr Burns, you are using the language of progress and improvement, but when we look as a committee at the Audit Scotland report, here are two examples. The per cent of A&E attendances seen within four hours dropped from 83 per cent in December 2019 to just 62 per cent in December 2022. The same paragraph 37 of the report delayed discharges increased to the highest level since 2014-15, so that does not sound to me like progress and improvement. It sounds not that we are going forward but that we are going backwards. My early remarks were referencing our work in planned care. I would fully accept that, in terms of unscheduled care, as measured by the accident emergency for our standard, no one finds that an acceptable position. Again, we are working to deliver improvement, to ensure that we are able to do that. That standard of four hour wait, we are working again across Scotland, so we have a range of improvement programmes. We are looking at high impact change. We are looking at the process of discharge to ensure that that is, as was said by Caroline earlier, 97 per cent of people. Our discharge from hospital without delay, but we are seeing longer length of stay in hospital compared to pre-pandemic. That, of course, is contributing to the occupied bed days and the occupancy and then the delays through A&E. I would say that we are also looking to deliver care differently. We have a very effective delivery of our out-of-hospital pathways. We have seen a doubling of our out-of-hospital bed equivalent capacity in Scotland through hospital at home, through community respiratory pathways, throughout patient-parental antimicrobial treatment pathways, where we are delivering that care in the community. We are looking at further ways to extend that through other pathways such as heart failure. That is bringing additional capacity, but it is also enabling our teams across the acute and community to deliver care differently. That is an important part of how we improve the measures that you have described and how we improve the experience for patients. We are very focused on delivering those improvements. We are working with boards across Scotland and boards have their own local improvement plans for making change and to make improvements to that standard. That might be a question for Caroline Lamb, but one of the part of the analysis that is contained in the Audit Scotland report is that the NHS recovery plan, which was launched in August 2021, was that it did not come as a result of proper consultation with the territorial health boards at all. I think that there was a commitment, a political commitment, perhaps given that within 100 days of the election in 2021 the NHS recovery plan would be published. The consequence of that, according to the analysis in this Audit Scotland report, is that the health boards were not involved in that. Is that a matter of regret to you? I think that clearly we want to, wherever we can, work with boards. The recovery plan that was published in August 2021 was based on what additional capacity we thought we could provide into the system. That was very much through new areas of work, such as the national treatment centres and also the work that the Centre for Sustainable Delivery was doing around improvements to create more capacity, particularly in outpatient clinics. We did work very closely with the Centre for Sustainable Delivery, who were in contact with all boards around those opportunities for improvement. As we move forward, we thought that we might be completely coming out of the pandemic at a point in time that we thought we might be completely coming out of the pandemic. Then we were hit by Omicron and we had to go back much more into Covid management, with three big peaks of Omicron going into 22. As John Scott described, the work that we continue to do is very much around working to look at the picture at a national level and how we can best use national resources, but also very much predicated on working with individual boards around their particular challenges and what we can do to support those. Presumably, you agree with the recommendation in the report that the Scottish Government and NHS boards need to work more collaboratively in the future than they have been in the past. I absolutely accept that our NHS boards are our key delivery partners as our IJBs in relation to social care. We absolutely need to work with NHS boards. Richard's teams work really closely with boards around their financial position. John's teams work really closely with boards around their trajectories for planned care and for urgent and unscheduled care, so we are working very closely with all those partners. I think that the conclusion that is drawn by the Auditor General is that you need to work more closely with the NHS boards. Perhaps the Auditor General has given that, again, this is a reporting time. If the Auditor General were to look at the range of working that we have going with NHS boards at the moment, the improvements that we have made to the detailed planning guidance, the extent of consultation with NHS boards before we issued that detailed planning guidance. I hope very much that the Auditor General will accept that we have delivered a lot against that recommendation. We have been told a few times that it is a moment in time, but the report came out in February this year. I know that we are now in the month of May, but it is not that long ago. One of the headline recommendations in the Auditor General's report is that you should revisit the NHS recovery plan. Are you doing that? Are you planning to do that? The planning that we are doing at the moment with boards is aimed to absolutely get more granular detail around what we can expect to deliver and by when. In essence, yes, we are going through that work at a very significant level of detail. We have learned a lot. The August 21 report at that point, I think that we all over-optimistically thought that we were through Covid and we weren't, and then we were hit by additional respiratory illnesses last winter as well. We are also very mindful of needing to just play in different scenarios around the impact of those shocks on our planned care system as well. I am going to move on now and invite the deputy convener, Sharon Dowie, to put some questions to you. Good morning. What steps the Scottish Government is taking to reduce reliance on bank and agency staff and to reduce the significant increase in expenditure on this? Absolutely. We have a short-life working group that is jointly chaired by one of our chief execs, Calam Campbell from NHS Lothian and our chief nursing officer, Alex McMahon. They have been working through a number of measures aimed at reducing reliance on bank staff, but particularly agency staff because it is agency staff where we get the extra expenditure, premium expenditure. We have also been looking at what measures we can do to enhance recruitment into NHS Scotland. Clearly, the call-on agency staff comes particularly when the system is under pressure, when we have additional beds open and we are needing to find staff to look after the patients in those beds. It is important to recognise that, overall, the workforce in NHS Scotland has increased since pre-pandemic. We are up by about 9.5 per cent, so total whole-time equivalent numbers at December 22 were at 156,000 compared to 142,500 pre-pandemic in December 19. Within that, we recognise that we are seeing real pressures on urgent and unscheduled care. We have had to open extra beds, and clearly that is leading to a reliance on agency staffing that is much higher than we would want to see. Rich has already reflected the fact that we are the only nation in the UK that has not seen industrial action from healthcare staff. That is really welcome in terms of our ability to manage the system and reflects the fact that we have made a very good and fair deal with Agenda for Change staff. We have also been putting into place a number of other initiatives aimed at supporting staff to continue to work in NHS Scotland or to do additional hours for NHS Scotland. Those include our retired to return policy, which is aimed at supporting people who have retired to come back and to work on a flexible basis for NHS Scotland. We have also looked at allowing boards discretion to look at how they use the pension contributions. That was before the changes to pension legislation was announced and the tax implications of pensions. We have been seeking to recruit additional nursing and allied health professional staff through international recruitment. We achieved 200 additional staff by summer last year. That encouraged us to allocate additional funding to enable boards to recruit up to an additional 750 staff from overseas. The early indications are that boards have exceeded those targets but that is not yet. We are working on looking at that data and hope to be able in a position to publish it shortly. We are also concerned that we should look quite broadly at entrances into nursing programmes. Alex McMahon, our chief nurse, has been leading a lot of work around the band 2-4 in Agenda for Change, with a view to ensuring that those staff have access to opportunities to develop and progress their careers. That was linked to creating an additional band 4 post and recruiting into those. There is a huge amount of work under way that is aimed at ensuring that boards have access to staff that reduces their requirement to go to agency and locum staff. You spoke a lot there about recruitment. What is it that you are doing to retain the staff that you have already got? A large amount of the junior doctors once have completed foundational year 2 seem to be taking a gap here because they are saying that they are overworked and exhausted. What is it that we are doing to retain the staff that we have already got? I think that I have figures that say that 20, 21, 22, 15,000 NHS workers left the health service. I know that you have just said that we have increased it to 156,000 now, compared to 142,000 pre-pandemic, but there are still a lot of staff that seem to be leaving because they are overworked. What are we doing to retain the staff that we already have? In a workforce that size, we are always going to have people leaving through retirement, through change of circumstances. Clearly, we want to try to hang on to as many people as we can. Part of that has been resolving the pay issues and getting to a point where we have made a really good pay offer to agenda for change staff. We have encouraged all our boards. We have a national wellbeing hub with around 200,000 using resources on that. That is about supporting people in a rate or signposting people to different resources. Lots of opportunities are there. That point about career progression is really important. Ensuring that those people who want to develop their careers within NHS Scotland have an opportunity to do that and have an opportunity to do that in a flexible way as well. We are always going to need to keep focusing on recruitment because we are always going to have people retiring. Equally, we are very concerned to look at hanging on to the people that we have as well. You mentioned the pay, but a lot of it is to do with working conditions as well. Recently, I have spoken to some doctors. Some of the comments that they are coming up with are that there is no compensation or time off in lieu for having to stay late at work. I have been expected to come in early. No rest facilities for night shift are on calls. Sometimes, if they do manage to get a chance to get a break, they are having to put two chairs together to try and get a sleep. It is being told that they cannot attend otherwise mandatory teaching sessions as workload and staffing do not allow it. The list goes on. Those trained doctors are not going to stay if that is the conditions that they have when they are doing their training years. What more are all health boards involved in looking at working conditions for the doctors? Absolutely. We want to ensure that all health boards have, at the top of their agenda, the wellbeing of their staff. That includes providing those physical resources so that people can get a break as well. In relation to the junior doctors specifically, through NHS Education for Scotland, we pay attention to the feedback that we get from junior doctors through the trainee survey. That is part of the overall work that NES do in working with NHS boards where there are issues identified around training programmes for junior doctors and looking to put in place action plans to address those. That is part of the mechanism within the system for ensuring and seeking to ensure that the quality of our training experience for our juniors is as high as it possibly could. You are absolutely right. We want those people to have a great experience because we then want them to stay and work in NHS Scotland. I understand that when you are involved in an intensive training programme, a lot of people feel that they just need a bit of a break from that. A number of our boards, John's former board was one of them, have put in place arrangements for clinical development fellows that enables juniors to take a year or more out of quite structured training programmes. Maybe it gives them a bit more space to think about what are the specialties that particularly interest them and where do they see their futures. I think that it is genuinely recognised by juniors as providing them with a really positive experience. John, do you want to say anything about your experience from Ayrshire and Arran? I can, yes. We recognise the need to develop that role because there are doctors who, as they decide on their training route, may want a bit more time. We created those posts to also support and give them some time where they could do further academic study, research and provide service. I think that it is really interesting to engage with community as well. We had individuals who would provide service to local sports clubs and so on. That is just an example. I know that many boards now look at those roles. That is an excellent way to retain doctors in Scotland because it gives them that extended opportunity. It also means that they can then consider what their next steps are for their training career. I have been out of Ayrshire for a couple of years now, but the feedback was excellent from those doctors. They saw Ayrshire as a place that having been supported, having had that opportunity, they would want to come back to the future, perhaps for a consultant role. That is the sort of programmes that add that value and that retention point that you referred to. Can you tell us more about what funding arrangements the Scottish Government is putting in place to ensure that Scottish students have access to places in medical courses offered by Scottish universities? I think that that is probably something that we will need to come back to you around the specifics of the funding arrangements. We can certainly provide you with that information. When you put out an announcement, there was one that we were going to have 800 more GPs. Is there conversations between NHS Scottish Government universities to do a workforce plan and to see how many spaces you are going to need in those courses? To take the GP programme as an example, the things that we have done there have increased the number of medical school places. We have increased the number of places in medical school overall. We also set up ScotGem in St Andrews University, which is a graduate programme aimed at people who have a particular interest in primary care and also through the training elements, a particular focus on remote and rural care as well, recognising that that is an area that we need to be able to recruit to. We set up ScotGem in order to provide that pipeline through medical school over and above the more traditional medical school, which is obviously the people who come through that route who want to train to be GPs. We have now increased, so we then have to increase the specialty training pipeline. The numbers of training places that are available for people in the GP specialty programme as of 2022, the total numbers available in that programme were 326 and we recruited to 322 of those places. That is probably the highest fill rate that we have had for GP for a number of years, possibly since records began. I will check that and get back to you on that detail. That is an indication of the fact that we have increasingly managed to develop a strong pipeline through to general practice. Those things take some time because you have to encourage students through medical school and then into and then provide the places but also the good quality experiences through that specialty training as well. If you are doing workforce planning and you see that there is a gap and you need more students on certain courses, you do have conversations with universities? Yes, absolutely. The conversations that happen with universities around undergraduate medical places and the numbers that are required there. Through NHS education works with specialty boards to look at what the projected requirements are for consultants in each specialty. We have had a particular focus on GP there, in order to make sure that students coming through medical school have the opportunity to train in the specialties that we know we are going to need. I know one of the big issues with universities is that there is obviously free education in Scotland and there has been talk of less Scottish students being able to get in the courses because they are having to take students' own that are basically paying fees. I do not know how true that is, but I did in one recent dentistry course that was completed. There were only three people in the course that were Scottish and the rest were international. I cannot say that that is actual fact, that is what I was told. I know that you will not have them just now but you will be able to give us figures showing how many places Scottish students are getting on medicine dentistry pharmacy. Is there any update on the completion rates of those as well so that we can see how many Scottish students are completing courses in our universities that can stay on? I definitely do not have it in front of me right now. I am also just going to say that we are dependent on the universities for that breakdown, but I will check with colleagues whether we are able to get that from the universities for you. Can you also tell us whether the Scottish Government agrees that the target to increase GP workforce by 800 by 2027-2028 is on track? My previous answer, I have told you about some of the things that we are doing to build towards that. I think that it is really encouraging that the training numbers in 2022 were up to 322 people now on training courses on that specialty training programme to be GPs, which is a three-year programme. I think that we are building towards those numbers. What I would say is that we have also put a huge amount of investment into increasing the multidisciplinary team around GPs and the team that supports GPs. Pharmacists, advanced nurse, practitioners, physiotherapists to support GPs in order to be able to free GPs up to do that sort of expert generalist role within their practices. We have up to 3,220 people who have been recruited to those multidisciplinary teams across Scotland. Do you have any figures as well? We have got the figure of its 800 GPs, but its head count, whereas what I hear as well is that there are a lot of GPs that are now going part-time, so if you have 800 GPs that are working five days a week, that is one thing. If you have got 800 GPs that are only working three days a week, then that takes about 300 GPs off your figure. It is just so that it is not misleading. We say that we have got 800 GPs, but if we recruit GPs and they are all working part-time, then we are not actually getting those full-time equivalent GPs into... I absolutely accept your question and clearly we have an issue in terms of people increasingly, particularly in general practice, wanting to work less than full-time. Again, I will see if we have that information because again that would need to come from individual GP practices. How successful the Scottish Government's international recruitment strategy has been to date and whether international recruitment will form part of future workforce plans? I think our international recruitment strategy has been really successful to date. As I mentioned earlier, we had recruited 200 staff by August last year and that encouraged us enough to put some additional investment in to enable boards to recruit up to an additional 750. Early indications are that we will certainly meet those numbers and that some boards have taken the opportunity to go further than that because clearly again that is a resource that they can balance off against the need to use agency staff. The feedback from NHS boards, many NHS boards are finding that a really helpful and useful resource. However, that is not uniform across Scotland. There are areas of Scotland, particularly where housing is a challenge, where it has been more difficult to bring people in from overseas. On the retention side, are you looking, because it is an extra premium when you are taking on international staff, are you looking at tracking the retention rates for international staff compared to domestic staff? Yes, we are looking at how we can ensure that we keep international staff, albeit that they may want to move around Scotland. Before I do that, we have spoken about the number of GPs and recruitment and retention and so on, but one of the issues that the committee was quite exercised by last year and we took up with you in correspondence was that broader picture of GP data. On the one hand, we have GPs saying that we are seeing more patients than ever and on the other, our post bags are full of people saying that they cannot get an appointment with a GP. I think that we were quite keen to have some transparency over that. We certainly corresponded with you, Caroline Lam, about an oversight group that you had put together that was an attempt to try to get into some of that granular detail. I just wondered whether you could update us on that work. Yes, absolutely. I share your keenness to have access to that level of granular data. We have a wealth of data around our acute sector performance, but we have had to put in place mechanisms to build our data in other parts of the system. Social care is another area, but primary care is certainly one as well. When we met last year, Sir Lewis Ritchie was chairing an oversight group that was looking at data within primary care. Public Health Scotland has been working on mechanisms to make that data available from individual GP systems. At the moment, we have produced some publications around GP activity and have managed to make that available both at a national level and at an NHS board level. I would say that we have some issues in the quality of that data because of things being coded differently in different GP practices. There is still some work to do on that. We have now started the roll-out of the next generation of IT to GP practices. We hope that that will help to improve both the ease of extracting data out of GP systems but also give us a position to be able to start with a bit of a clean slate around how data is coded. It is an extremely challenging position and I talked about the multidisciplinary teams earlier and how we need to be able to track not just those that activity in the patient contact from the GP perspective but also recognising that it is often much more appropriate for somebody to see a physio or a pharmacist rather than a GP. We all share that desire to be able to really understand that data and therefore understand where our opportunities for improvement are. Obviously, as a public audit committee, we are interested in the public accountability of that service. The only way we can get that is by having that data and having that degree of transparency. I think that if I could just re-emphasise, you may share our frustration but if I could just re-emphasise to you that we do think that that is extremely important because it is, for many people, the access point to the national health service. Craig Hoy, you've got a question. I attended last year a round table with the RCN, the chief nurse, the former cabinet secretary for health and frontline nurses. One of the things that struck me was that simple but presumably effective mechanisms like exit interviews weren't necessarily being routinely deployed throughout the service. We're interested to get a confirmation that that is now the case and that we're perhaps using more of those tried and tested practices. Do you think that you have a sufficient handle as to why people are leaving nursing, for example, and how responsive are you being to those key messages that you're getting as to why people are leaving the service? Excuse me, I think that there's more we can do around being clear about the reasons why people might choose to leave nursing and therefore to get a better understanding about what more we can do to keep them. We have recently established a nursing and midwifery task force, which is looking at a number of the issues around both recruitment and retention and the opportunities for how we best use our nursing and midwifery workforce and that's one of the things that that task force is looking at. So, would it be fair to say that you think that at this point in time you're not doing enough to capture the information as to why people are leaving the service? I think that we could definitely improve the data that we have available to us. At a board level and at a national level. Okay, thanks. I'm going to turn for the final series of questions this morning to Bill Kidd. Bill, I'm going to bring you back in. Thank you very much, convener. Just a wee bit about reform and innovation and how that's being used by the Scottish Government and NHS boards. There's a necessity, as I think I've said, that there's a need to monitor public awareness and acceptance of new ways of assessing services to make sure that they're effective. I might need to go myself to a hospital. Hold on, if you don't mind. I do like a bit of melodrama. I'm looking at the fact that the public need to realistically understand what is being achieved and to try to involve them in difficult choices. How effective is the Scottish Government's redesign of urgent care programme in reducing the number of people who self-present to hospital and feedback, therefore, received from patients about the service changes that have been made? I'll take that one. I think that the redesign of urgent care has been a successful programme. I think that it's an area that we need to continue to evolve and develop. I think that it's been successful. Of course, looking at the period of the pandemic and trying to make sure that we're comparing effectively, we have seen a reduction in self-presenting attendances, and that was always the intent that we would see a reduction in self-presenting attendances. I think that that's a number of factors that have supported that. I think that, firstly, the work that NHS 24 undertake and the NHS inform, we know that that's accessed. I think that for March, I think that the figure was around 12 million people accessed the NHS inform and for that able to access self-help guides. I think that we've also had very effective communication with the public over time about right care, right place and how to access services. Although that is your general practice, I say that because it could be a nurse or a pharmacist or a physio, or whether that's your community pharmacy. We've seen some excellent progress in terms of the role that an important role at community pharmacy plays. We've also introduced flow navigation centres across every board in Scotland through the redesign of urgent care, so that individuals may be referred by NHS 24 to the flow navigation centre. They then will be either directed or redirected again to the right care, which isn't always needing to attend an A&E department. The final thing that I want to comment on is the excellent work that Scottish Ambulance Service has made in relation to the clinical advice that they can provide when someone calls. Secondly, the ability for their skilled paramedics and staff to manage and provide care at an individual's home and avoid conveyance to hospital, but also by getting support through the flow navigation in a peer-to-peer conversation. All of those factors have impacted and allowed us to provide care differently that avoids unnecessary admission or attendance at an accident emergency department. It has a lot to do with monitoring public awareness of the changes that are being made and its acceptance of new ways of accessing services to ensure that it's being effective. You've said that there have been changes and we know that the professionals are seeing how this works. Is the public awareness of this, though, is great? Can it be improved in order that the care and wealth being portfolio can bring about the reform necessary to improve public health outcomes? The monitoring and the reportage that comes from that can give us all comfort that this is achieving where it is there to do. Is the public aware of these changes enough? We've consistently, for a number of years, had public messaging and marketing that has signalled those changes. We've also done leaflet drops to every household in Scotland in the past, setting out that range of services. Most recently, and I should have made reference to this earlier, we have introduced an NHS 24 online app with access to self-help guides through the app. That's an area that we're developing. It's an area that we think has further opportunity to make more accessible services as people tend to look to and use apps more. Perhaps more readily for accessing information. That's an important development that we will continue. We will also know through some of the evaluation of the marketing that that has been impactful in terms of how people across Scotland have looked to use and access services. I do think that when we look at our own data, we're seeing that shift in where care is being accessed. There's always more that we can do in measuring the impact and we will want to stay sighted because as we progress urgent care, there will be more that we can do in terms of some of the pathways of care where we can support people in a different way. We'll continue to do that. We'll need to make sure that we're continuing to ensure that our understanding and data collection and reporting of that impact is matching and following those changes. That's helpful. Thank you very much. That pretty much brings us to the close of this session. There were just two things that I wanted to highlight in the report that I'd welcome your views on. One is this whole agenda for reform. The clear message from the Auditor General is that the level of funding for the NHS at £19 billion is at a record level, but yet we are still continuing to see outcomes suboptimally. The debate about what we need to do to change, to reconfigure services, is something that is central to that. Some of that goes back to the Christie commission of over 10 years ago about that preventative agenda and that broader view of public health, not just the institution of the national health service. That really rests upon public debate and engagement. I guess that it would be useful for us to find out from you in closing what your perspective on that is and what your plans are for that. The other thing related to that is, again, one of the key recommendations in the report, and you said that you accepted those recommendations, was that you should publish annual progress updates on service reform. Is it your intention to do that? I absolutely agree with your analysis that this is about tackling the broader public health issues, but it is also about how we provide services differently, how we use innovation and technology to provide services closer to people in their homes, and how we provide services in a much more preventative way. The example of the closed-loop diabetes is a clear example of where we can prevent people's health from deteriorating by using relatively simple technologies. I think that in terms of looking at how we publish our progress in relation to innovations, we do some of that already. We produced a publication after the pandemic around how we would use digital health and technologies to deliver services differently during the pandemic. A lot of those things remain in place, so NHS near me and the huge increase in the use of that would be an example of all of that. I think that it is very useful for us to make available some of the evidence around the impact of that innovative work, whether that is an annual report or whether that is focusing on different areas of activity. That is okay, but I take it from that that your answer is not yes that you accept that recommendation from the Auditor General. I accept the recommendation that we need to be able to publish information about the impact that innovation and changes the way in which we deliver services can make, whether that needs to be a dry annual report or whether there are ways of doing that differently. I think that that is something that we would want to reflect on. I am sure that the Auditor General was not suggesting a dry annual report, but something that would be informative and would help people to understand the progress that has been made. Of course, we have highlighted some of the areas where we have concerns, but there are, as you said at the start, not least thanks to the workforce, some extremely critical work that is going on out there. As a committee, we would like to add a record of our thanks to yours for the incredible work that the staff providing those services do day in, day out, night in, night out. On that note, I would like to close this morning's session and thank Caroline Lamb, Richard McAllum and John Burns for your input this morning. It has been very useful to us. There were some areas where you said that you might get back to us with a bit more detail in your answers, and that would be most welcome. I thank you again and I will now draw the committee's public session to a close and move us into private session.