 I welcome everyone to the 10th meeting of the Public Audit Committee in 2022. The first item for committee members to consider is to agree or not to take agenda items 3, 4 and 5 in private. Are we all agreed? We are agreed. Thank you very much. The main item on our agenda this morning is consideration of the Auditor General for Scotland's report on the NHS in Scotland 2022, which was released exactly a month ago today. We are very pleased to welcome with us in the committee room this morning to give evidence on that report. The Auditor General, Stephen Boyle, is joined by the Executive Director of Audit Scotland, Anthony Clark, senior manager at Audit Scotland, Lee Johnson and senior auditor at Audit Scotland, Fiona Lees. We have quite a large number of questions to put to you this morning, because it was quite an impactful report when it was produced. Before we get into those questions, Auditor General, can I ask you to make a short opening statement? Many thanks, convener. Good morning, everybody. I am pleased to bring to the committee this year's NHS in Scotland's report. The report focuses on the Scottish Government's NHS recovery plan and it also looks at the progress-to-date against the ambitions in the plan and examines the challenging operating environment and the impact that that is having on progress to delivery of the plan. The NHS continues to be affected by the impact of Covid-19 and a growing range of financial and operational challenges are making progress with recovery extremely difficult. NHS finances remain under severe pressure in spite of growing health spending, rising inflation, increasing recurring pay pressures and on-going Covid-19 related costs cast doubt on the financial sustainability of health services. Both the legacy of Covid-19 and a challenging winter period are affecting how the NHS operates. The flow of patients through hospitals continues to be impacted by issues in the social care sector, leading to pressures throughout the healthcare system. The backlog of care that built up during the pandemic continues to grow and the health and wellbeing of people waiting for treatment is being negatively impacted by longer waiting times. The Scottish Government's NHS recovery plan was intended to tackle the backlog of care and drive forward innovation and reform to make services more sustainable. However, it lacks detailed actions that would allow overall progress to be accurately measured. It is already clear that delays to opening some of the series of new national treatment centres will mean that targets for increasing planned care activity will be missed. Some key recruitment targets with the recovery plan are not currently on track, some are, but that risks successful achievement of the recovery ambitions. Convener, reform is essential if NHS services are to be delivered sustainably in the long term. Urgent action is needed on tackling the long term demand for NHS services by improving people's health and reducing health inequalities. There is some progress in innovation and reform, which is welcome, but this is at an early stage and its longer-term impact is not yet known. It is vital that the Scottish Government presses ahead with these areas and monitors progress carefully to ensure that innovation and reform is having a positive impact. It must also make sure that there is clear communication with the public on how these services may change in the future. Lastly, the report highlights the need for greater transparency on progress against the Scottish Government's recovery ambitions and on clearing the backlog of care. The Scottish Government must make better use of its annual progress updates on reporting against the recovery plan to provide an accurate and comprehensive summary of progress. My colleagues and I look forward to answering the committee's questions as best we are able to. Thank you very much indeed. Without further ado, I would like to begin that questioning by inviting the deputy convener, Sharon Dowey, to open up. The report highlights significant challenges facing the NHS in Scotland while noting that healthcare systems are under extreme pressure across the world. How is the NHS in Scotland performing compared to other countries' healthcare systems? I say right from the outset that this report does not look to draw that comparison deputy convener in terms of the Scottish NHS relative to healthcare systems across the world. I will bring in colleagues in a moment. Maybe Lee might want to elaborate. What we look to do in today's report is to update on the progress against the Scottish Government's own recovery plan that it produced in 2021. Our general message from that is that it is proving extremely challenging to deliver all of the ambitions. Before passing to Lee, I think that the Government has been clear in its communication of the extent of pressure that NHS in Scotland is facing. We all saw over the winter period with the scale of winter pressures and heard from the Government that it is an extremely pressurised challenge system in Scotland at the moment. There are some international dynamics to our report today, but we do reference the reach that the Government is looking to have in the NHS in terms of broadening its international recruitment. However, the report itself does not look to draw an evidence-based comparison between the Scottish NHS system and other systems elsewhere. Lee might wish to elaborate on that. I do not have much to add, as the Auditor General has said. We are not trying to draw comparisons in that report, but all I would acknowledge is that we know from other audit agencies across the UK, for example, that the other healthcare systems are facing the same issues in terms of growing backlogs of patients that need to be seen and the challenges that they are facing in trying to address that backlog in care. The report also states that Covid-19 spend will no longer be monitored, given your call for transparency and recovery progress. Is it premature for the Scottish Government to stop monitoring that spending? As we have discussed in some of our recent reporting and I have updated the committee on that, there is now no separate Covid-19 budget line in the Scottish budget. For the committee's awareness, we committed to rounding off our Covid-19 reporting, and we will do that shortly with a web-based publication that sets out the totality of Covid-19-identified spending relative to actual spending, which is due to be published relatively soon. If I may, I would say that that relates, yes, to Covid-19 spending, but as a wider point, firstly, on Covid-19, as I said in my introductory remarks, Covid-19 still has a significant impact both operationally on the Scottish NHS but also on the financial implications of it. I might just draw the committee's attention to appendix, if I get this right, my notes. Fendix 2 sets out some of the in-year forecasts that NHS boards in Scotland are making. You can see from that table that there are still very significant financial challenges. Transparency matters, whether it relates to Covid-19 expenditure or to the wider performance and financial position of NHS boards. Ultimately, it is within the gift of the NHS and the Scottish Government as to whether it continues to identify Covid-related expenditure. I think that the indications that we have had is that that will cease to be the case, and there will not be a separately identified budget for it. It does not detract from the overall need for transparency in the mill. What is your assessment of the progress of the Scottish Government's Covid cost improvement programme? I will bring colleagues in a moment to update the committee on that point. The overall position that Covid-19 has dominated the services of the NHS in Scotland for the past few years. We are looking now to see the delivery of a recovery plan and a clear plan that relates to the lingering effects of Covid-19, but moving to a position of stability that captures both transformation in the longer term and clear, transparent performance in the short term. Lee may wish to sit a bit more about Covid-19's wishes. The Covid cost improvement programme, we know that there has been reductions made. For example, Covid costs for this year are predicted to be about £723 million, but we know that that is a reduction from earlier estimates. Boards have been working hard to try and reduce the costs related to Covid, so that is things like PPE, the vaccinations test and protect, as well as various infection prevention and control measures. Each board was given a funding envelope to cover its Covid costs, and it has worked very hard to try to keep its costs within that funding envelope. Will all health boards follow the same guidelines? If we are not monitoring the spending, will we run the risk of some health boards spending a lot more in Covid than others? Are some not spending enough on measures? I think that the spend will vary across boards. I think that they are monitoring it this year, obviously, because they have that funding envelope. I think that what we are talking about is going forward into the following year. The hope is that Covid costs become part of the core funding and core operation. It will not be separated as being Covid related any more. As I have said, things such as the infection prevention and control measures that are required, PPE and that kind of thing on-going will just become core costs. There is now no additional money from the UK Government to cover our Covid costs, so it has to become part of the on-going health and social care budget. Just to make the point that this is an area of interest to us, because it is part of the efficiency drive across the NHS in Scotland. We are, through Lee and others, looking to see how effective this recovery programme is. It might be lessons that the NHS can learn, in other ways, of identifying and sharing good practice. I think that your question, Sharon, implies that is there learning and good practice being identified and shared across the boards? I think that our sense is that the Governance around this is trying to do that. Willie Coffey also wanted to comment on that question. I thank you, convener, just briefly on that point. Auditor General, the table you shown in the exhibit shows £723 million of Covid spend. The next column for 2020-24 says that it is not yet known. Do you mean that we anticipate that that level of funding will still be required to support Covid initiatives from the Scottish Government, but we just do not know the figure? It is not that that money will be lost. Do you anticipate that that will still be required? I have a number of factors to expand on, Mr Coffey. I think that the money will not be lost, but it is the extent to which the NHS in Scotland, the Scottish Government, wishes to monitor and report on Covid-related activity separately. I think that we can all assume that the size of Covid spend will ebb further from the peak where we were a couple of years ago. Obviously, today marks the third anniversary of that, but we can safely assume that there still will be some Covid-related expenditure. Lee rightly mentions that there are infection control measures that are required within hospitals for Covid-related patients. What it will not be is of the scale that we have seen previously. We do not have a figure. I would say that there would be no harm in the NHS in Scotland continuing to monitor the scale of expenditure, but we can assume that it will be lower than it has been up until now. I reflect that the terms of debate in this Parliament on the NHS, which is a very high priority for all of us, is often a contrast between inputs and outcomes. I note that, in your report, you note that there has been a £4.4 billion increase in NHS spending since 2018-19, and that the budget for 2023-24 is estimated to be over £19 billion. You assessed that as being three years earlier than anticipated, so there is no question that there is substantial public investment going into the NHS, but yet we do not see outcomes necessarily improving. Is it just funding that we need, or are there other factors that are necessary to be applied in order to rise to the challenges that we are facing in the national health service? That is the nub of the vital issue. The committee may have seen the publication of the past day or so of the Scottish Fiscal Commission's report that looked at casting an eye over the next five decades of what public spending in Scotland might look like. That report suggests that there will be a 10 per cent drift of income and expenditure, and that is largely attributed to the increase in the rate of health spending in Scotland, which suggests an unsustainable model if we continue at that rate. I want to come in and talk about the key to unlock some of the change, and I do not wish to glibly talk about reform, but unless we move to a preventative model that tackles health challenges and encourages people to live healthier lives, we do not have a sustainable health system in Scotland. That is the real onus upon leaders to make that kind of change. There are some very good examples in today's report about where some of those innovation and reform is happening. Scaling those up to make the significant change to improve the health of the people of Scotland is so important to deliver better health for all of us that we want, but also a ffiscally sustainable approach at the same time. You are quite right, convener. The issue here in many ways is about the burden of ill health that Scotland faces and the long-standing issues that we are aware of of the inequality of health outcomes across Scotland. The way that the Scottish Government has tried to organise its care and wellbeing portfolio recognises and acknowledges the importance of focusing on prevention, working with partners to make sure that we can, if you like, change people's behaviour and work on the determinants of ill health around things like employment, housing and wellbeing. That is a really big issue for the Scottish Government that they have recognised. Exhibit 12 of the report sets out some of the things that the Scottish Government is trying to do to drive this reform. It is about coherence across Government, getting different bits of Government to work better together. It is about being clear about what a sustainable model for the health service looks like. As the Auditor General says, that has to be about reforming and changing how health is delivered. However, it is also about what we do as individuals. That focus on public health interventions and changing people's behaviours is really important. The report indicates that it is still relatively early days for that. We reported on this in the last overview. You can expect this to have a much greater prominence in our future NHS reporting, because we are keen to explore and report on how, effectively, the health department, the care and wellbeing portfolio, is working with those to make that shift. That is really important stuff if we are going to have a sustainable health service. Those broader questions are ones that we have touched on before are around inequality and poverty. Those are often the drivers of the demands that are placed on the national health service. It is a broader public health question and a societal question, which we probably have not got time to go into this morning, but it is an important thread that runs through this. I now apply the handbrake and jump on to something else, which is related but quite different. In the report, you talk about the capital backlog maintenance budget, which has always been something that has been the focus of attention in previous years. Again, there is a long-standing critique, is not there, about why should it be backlog maintenance rather than proactive maintenance? If maintenance is carried out on an on-going basis, it becomes less reactive and probably more cost effective, but that might be another argument or debate for us to have. However, the question for this morning that I want to put to you is, in the report, you indicate that it is proposed to double investment in the capital backlog maintenance budget over the next five years. Given all the other pressures on spending in the national health service, how confident are you that that is going to be an achievable goal? You are right that the report sets out that that is the Scottish Government's intention to double its investment in backlog maintenance and other maintenance over the course of the next five years. For the committee's attention, we also referenced in that same paragraph a report from 2020 on NHS capital maintenance backlog at the time that the figure stood over £1 billion. Steffan, back for a second. Those are about health and safety and appropriate conditions that people who work in the NHS and those who are receiving treatment. Of course, we have to invest in our estate to maintain the standards, not just in the new bills. The committee will be interested in the national treatment centres that are part of the key strand to deliver additional capacity in the NHS to address the recovery ambitions. However, at the same time, it is just as important to maintain the quality of the existing estate. You asked me directly, convener, how confident I am. I think that we have to continue to track and monitor that. It is vital that it is done consistently. There is temptation across, particularly when times are ffiscally challenging to defer maintenance arrangements, not just in the NHS but across organisations that have to be avoided. Ultimately, all that is doing is deferring health and safety, and it will lead to larger investment requirements at a later date. We will keep an eye on that through our programme of work over the next few years. You will also keep an eye on that as it fits with net zero targets and the whole agenda of the public sector estate and how it needs to be changed substantially in order to meet those ambitious goals that we have on reducing carbon emissions. Very much so, convener. With the committee's agreement, we will be updating you in more detail next week on our future work programme that covers our intentions around net zero, but also the public sector estate. I will go back to some additional context around that. The use of assets by the Scottish Government as bodies and the wider public sector in Scotland was a key plank of the resource spending review from last year that sets out how we are using assets. It is a key driver for fiscal sustainability, the experience that people have of public services and public sector reform. We want to be part of that through our auditing work. Perhaps you can say further, as you wish, if that is convenient next week. We will return to that next week and beyond. I will bring Craig Hoyen, who has questions on one of those other important topics for us as a Parliament at the moment. Thank you. Good morning, Mr Boyle, and good morning to your colleagues. Obviously, you have said in the past to this committee that, in relation to the national care service, which is a huge piece of public policy work, you were not going to wait until it was created before you started to audit and analyse, particularly the numbers around it. In the report, you warned that the national care service will place a huge strain on the health and social care budget. Obviously, if the concerns have been raised in this Parliament, particularly by the Finance Committee in relation to the financial memorandum that associates, there are companies at the bill. That legislation is on pause now. What is your understanding as to why the legislation has been paused? Is it to look further at the numbers, do you believe? I will bring Antony in a moment. He has been closely monitoring this, so I can say a bit more. Audit Scotland, like many organisations, responded to the Finance and Public Administration's committee's call for evidence. We commented on the financial memorandum, to the extent to which there were potentially some significant risks of additional costs that had not been specifically identified in the financial memorandum that might come to fruition and ought to be considered in coming to a more rounded assessment of likely future costs. We also have a history, Mr Hoy, of undertaking audit work alongside the implementation of significant changes in delivery models or policy in social security Scotland. It is perhaps the most recent example where Audit Scotland has undertaken a programme of public audit reporting, although an initiative has been developed. A rationale for that has evolved over the course of the past 10 years. Historically, an audit organisation would have been entirely retrospective. Given that there is so much public investment at stake and such key outcomes for the people of Scotland, we felt that there was a role for us at a slightly earlier stage. We think that that is an appropriate parallel with the national care service. Antony, you can come on, if you wish, to say about the programme of work that we are thinking about and where that goes next. Thank you for the question, Mr Hoy. I think that our understanding is that the pause is so that the Scottish Government can reflect on the various views that have been expressed around the merits or demerits of the proposals that have been put forward here the two. I think that the sense is that there is broad acceptance that the issues highlighted by freely around the need for greater consistency, better support for workforce, better user involvement are all desirable, but there may be different ways of achieving those outcomes. I think that that is my understanding of the rationale for the pause at the moment. In respect of our work in this area, we were very clear in our submission to the Parliament on the NCS consultation that the issues that face the social care system around sustainability, quality, consistency, workforce support, need to be addressed now. We cannot wait for national care services to achieve them, so we are planning to do a suite of work focusing on particular themes and topics, looking at the issues that we highlighted in our briefing paper. Alongside that, the Auditor General's Colleagues at the Accounts Commission will be reporting annually on the financial health of integration joint boards, and that reporting is likely to expand to cover performance and outcomes over time in the period running up to the national care service. As the Auditor General has already said, if the decision is made to proceed with the national care service, we will want to audit the planning for that implementation, the effectiveness of the implementation and, in the longer term, whether or not the changes that are put in place deliver the policy objectives of better outcomes, better value for money and the more sustainable and high-quality service. That is a very important area of interest for us. Obviously, the report highlights that the national care service, if it proceeded, would be—and I think that the quotes are—a significant unknown financial commitment to be met from the Scottish Government's health and social care budget. To what extent are you concerned about the Scottish Government's ability to meet its spending commitments in relation to the NCS and the impact that that might have right throughout the healthcare system in Scotland? Maybe two things to see in response to your question, Mr Roy. The Scottish Government has to set a balanced budget every year, so when the Parliament considers the budget bill, it will prioritise. Spending commitments will be met, but it will come down to prioritisation of health and social care services relative to other parts of Scottish Government delivery. There is such relevance to the convener's earlier point and the fiscal commission's reporting that reform of health and social care is so important, so it is not a detraction from us about the merits or demerits of the national care service, but the Government and its partners are absolutely clear on what the intended outcomes are to be from the national care service. There is transparency, of course, and that is known and understood relative to other priorities. That is really what we are coming at it from an audit perspective. Except that two of the report highlights the considerable increase in delayed discharge. Mr Clark, you identified that action needs to be taken out to remedy some of the issues, because the whole issue about flow through the health service is not part down to a large part down to delayed discharge, which comes down to capacity within the social care system. The Government has announced plans to purchase 600 interim care beds with a 25 per cent uplift in the national care home contract rate. Have you made any calculation of how sustainable and how effective the short-term intervention might be? Is it going to deliver value for money in your view? I think that it is premature to make that detailed assessment. I am going to bring Fiona in at a moment who has looked to this as part of our reporting. Delayed discharges are a key part of the challenge here. We have seen through our work and have reported that having an effective whole system approach from the delivery of hospital-based services through to community-based services and interconnections between those are absolutely vital. We know and we have seen over the course of the pandemic and are currently experiencing that that is not all working as was before the pandemic and that it is causing delays in a hospital-based setting and some of the challenges to deliver health and social care. On the interim arrangements, I think that they are exactly that. They were designed to relieve some of the short-term pressures that were experienced as a result of winter pressures. What we call for in today's report is that there is a comprehensive plan around delayed discharges that involve both HHS and their social care partners to move to a sustainable care-based model. I do not think that I have too much more to add than what the Auditor General has already said. I think that it is too early to say what impact that has had. We have seen a slight decline in the number of delayed discharges since that peak in November. It is going in the right direction, but we need a bit more time to see what is going to happen. As the Auditor General said, we will have a long-term strategy that will solve the problem in the long-term. The national care service envisages a significant role for the private sector. Potentially some of us have argued a greater role for the private sector if local authorities step back from that. Looking at the true cost of care seems to be quite a fundamental issue at the heart of that. Even with that uplift, I looked at some numbers. The £832 a week as a national care home contract rate, 25 per cent increase, takes you up to about 1,040. Speaking to private sector care home providers who this scheme is meant to incentivise to free up capacity for delayed discharge, they are still arguing that that falls short of what they would perceive to be the true cost of care given their contending with cost of living crisis, higher energy bills and staffing cost pressures. It is part of the problem that until we identify the true cost of care and therefore properly fund care, particularly those who are not self-funding, and remove this element of cross-substitial. We are never going to get the capacity that will allow us to bring down quite aggressively those delayed discharge figures. I think that that is the essence of the challenge. I have stand up, and today, I think that Minister Moray has looked at some of that. Through the consultation from the committee on the pausing of arrangements, it is really to have, for all partners designed to take forward the national care service, it is clear that this is a sustainable approach to delivery. As Anthony Wreckley mentions in our reporting in the committee's interest in this over the past 18 months or so, there is an extremely challenging situation right now that cannot wait for a national care service down the line. There has to be both a short-term plan and a medium term, then a longer-term vision of the delivery of health and social care services in Scotland. So much of that relies on the partnership, both with Scottish Government, local authorities and private sector providers, to get it right to moving to that sustainable approach. Mr Hoy, Anthony, you can say a bit more as he wishes. I think that you are right, Mr Hoy. There is a very interesting question here around cross-substitiation and transparency of costs. I think that part of the work that needs to take place as a development of the national care service is what is the nature of the market we are operating in and what market mechanisms are going to be effective and appropriate to deliver high-quality care that delivers right outcomes but also protects a public person and delivers efficiency. At the moment, it feels as though those questions are a bit unresolved. Obviously, we understand that social care and the NHS are inextricably linked. Your report states that the Scottish Government's NHS recovery plan was not informed by detail and robust modelling nor were NHS boards involved in setting the ambitions of the plan. Further states that the Scottish Government is currently undertaking an exercise to model capacity across the whole health system. To what extent are NHS boards involved in this current modelling process and should it also include all elements of the social care sector to ensure that we have the capacity there for that displacement? I'll turn to Leah. She's done quite a lot of work looking at the construction and then the delivery of the NHS recovery plan. First, in our report, it's quite a high-level document when it was conceived at the height of the pandemic. There is some element of mitigation to this, Mr Hoy, that was done in 2021. We recall what conditions were like at that stage. However, it was not done on the basis of robust modelling nor did it widely consult with NHS boards. Through our report today, we have engaged with a number of NHS boards as part of our approach case study boards, just to test some of the experiences that they have had. We do say a high-level before passing to Leah that NHS needs a new plan, but it needs to report clearly and annually on the progress that it is making, informed by more detailed modelling that you suggest. In terms of the modelling, how involved boards have been in that would be a question for the Scottish Government. We are aware that they are working on it and, as we clearly say in our report, we think that this should be progressed as quickly as possible. It has been on-going for a number of months now, and we have still seen no evidence of what is to come or what is the result of that modelling. It is important that they progress that very quickly, but I think that, in terms of how involved the boards have been in that modelling, it would be a question for the Scottish Government. In terms of outcomes, the first annual progress report was in October 2022, and the first milestones of increased activity are in fall into 2023. If you were creating a dashboard now of those milestones of increased activity, is it fair to say that they are still flashing red or do we need greater transparency around them given that, obviously, that progress and recovery were meant to come to fruition this year? I think that there are lots of flashing red lights. We see that activity is still below pre-pandemic levels, yet the recovery plan had promised to increase the number of procedures and the amount of activity. Obviously, the NTCs and the national treatment centres are key to that, but there has been some delays to those for various reasons. Hopefully, once the national treatment centres come online, we might start to see some progress in that area, but, yes, I think that there has not been the increase in activity that we would like to have seen by this point. When we look at the 2023 report, would it be prudent for us to be pressing for greater transparency and more detail around what is actually being achieved? I think that the answer to that is yes. A clear progress report against all the intended milestones and all that was set out in the progress report is that Governments can change tack. If the Government intends to produce a new recovery plan, that is entirely in their gift, but what our report suggests is that, based on the current extant report, it is clear that progress should be reported against all the milestones within that. The version that was produced last year did not cover all the targets that were set out in the recovery plan. As we set out in Appendix 3 to the report, what we tried to do is give a fairly detailed analysis. You can see that there is progress against some of the measures in it, and the committee may wish to come on to explore that further, but what we have drawn attention to in today's report, particularly around the progress against waiting times backlog, is that that felt a bit general. People care most deeply about the specialism that they are waiting for, and if that is not set out in the report, the report can be less helpful, less relevant to them. What it suggested is that that is clear and comprehensive for all parts of the way that people use the NHS. I think that Willie Coffey wanted to come on a point around this whole area of questioning as well. Was this on the process of discharge? I was speaking with the chief executive at Ayrshire Narn health board recently who identified an issue that it is only consultants that can discharge a person from hospital. To be honest, I did not realise that, convener, but she was telling me that there is wider expertise in the profession that could discharge people from hospital, and I wanted to pick up whether you are aware of that. If we can address that particular issue, could that help the process of discharge? We can understand, convener, that people could be in hospital capable of being discharged, who are not being, because consultants are not getting to them in time to discharge them. Is that an issue that you are familiar with? Yes. I have been fionin who has looked at discharge arrangements more closely than I have, Mr Coffey, in the familiarity of it. First of all, I would say that I am respecting the professional judgment of clinicians, but I have seen evolving models in health and social care settings that are less reliant upon medical staff and bringing in the expertise of different specialisms in terms of how that is applied across the lead discharge settings. If you want, I can say a bit more, if not, we can come back to you in writing. That was not something that specifically came up when we talked to each of our case study boards, but it is certainly a really interesting question. I know that work has been done to improve the process of discharging patients, but the particular question that you asked is not one that came up, and I think that it is worth asking in the future. As colleagues have said, we have not explored this in great detail, but it seems to me that there are some quite important issues here around recognising the importance of the medical duty of care to make sure that people can be safely discharged and that it is appropriate for them to leave the hospital setting. My understanding is that it is not just medics and consultants who are involved in those discussions. Often you will have occupational therapists, clinical nursing staff and others involved. I think that the evidence in the report and our analysis of the broader systems problems would indicate that the problem here is probably less to do with the ability of consultants to make those decisions, more to do with the availability of support in the community to allow people to be discharged quickly. It is an interesting point that was made, convener, because she also said that junior doctors, many of whom have 20 years plus experience, are just as capable of making the discharged decision for a patient than a consultant. That is perhaps something that we could follow up for a future date, convener. Yes, absolutely. I am sure that we will return to that point. Can I just move things along a bit and turn to something that has been of interest to this committee, not only in this session but in the previous session? That is the financial position of individual territorial health boards. In the report, you suggest that, in your assessment of the 14 territorial health boards, only three are expected to break even, which means 11 are not. I presume that that does not mean that they will make a surplus. I presume that that means that there is a financial deficit that they are facing. We know that, in the past, that has led you to have to produce section 22 reports about health board conduct, because people have chosen to go down routes that have raised some concerns about where they have gone to get additional resources. I guess that the question that the committee has got today for you is, how fit for purpose are the brokerage arrangements? I think that so this term brokerage is about an intervention, isn't it, by the Scottish Government to help out individual health boards? I think that, at one point, it was based on a one-year time horizon, but it went to three. Can you bring us up to date on what the current position is and whether, in your estimation, those arrangements are going to be robust enough to get those health boards through the challenges that they face? I alluded to that earlier, but I will bring the committee's attention back to the heart of your question. Appendix 2 to today's report sets out the year-end forecasts that both the territorial and national NHS boards in Scotland are making for the end of 2022-23. You rightly say that only three of the territorial boards are forecasting that they will achieve at least a break-even position currently. It is probably reasonable to assume that the position will not be as bad as that at the year-end. There is an interesting example elsewhere in the report that one of our case study boards received additional funding when it identified to the Scottish Government that it had a cost pressure. Circumstances can be quite volatile. New money can be found either from funding arrangements from Government or savings identified by the board themselves. That has tended to be the way of things, rather than looking at the appendix. As it is currently to that, that will be the case by end of the year. That does not detract, convener, from the fact that there is a real financial pressure within the system currently. The report refers to inflationary pressures for goods and services, for pay arrangements. All those are driving costs up in the NHS. We have touched already this morning that the legacy of Covid has not yet been resolved and that is still reducing inefficiency. All of those factors are relevant. What we have said in the report, though, is a recommendation that, whether it is brokerage or otherwise, the Scottish Government needs to review the medium-term financial framework that it has in place for the health system in Scotland. What that looks like is forecast to allow it to financially plan into the medium term with more detail. It has a clearer understanding of the resources at its disposal, whether that means that it plans to make any revision to the brokerage arrangements to change to any of the funding environment. In effect, that is a matter for Government. What we are saying is that the current model needs a revision. Can I clarify my ignorance? On the one hand, you talked and I asked a question about the increase in resources, an additional £4 billion over the past five or six years. At the same time, the narrative in paragraph 24 of the report is about how health boards have to make savings. On the one hand, there is record-level £19 billion of public money going into the national health service. That is not a broader categorisation of public health, but it is going into the national health service. At the same time, there is a call on both national NHS boards and territorial NHS boards to make savings. Those two things feel contradictory, but they are both true at the same time. Funding is at record levels. Funding is always at record levels. The nature of the growth of public spending is that, in the context of NHS, it will continue to grow based on the projections that we have seen from the resource spending review in the Government's own forecasts. However, how far that spending goes is being constrained by cost of living pressures, inflationary pressures, purchasing food for hospitals, cost of medicines, dressings and so forth, and pay pressures. All those are eating into the extended capacity that the up to over £19 billion is offering. That leads to the well trodden path that the committee and predecessor committees have heard of, the need for boards to make savings. Where we get to is that I fear that we will always be in that position. There will be a growth in public spending and there will be a requirement for boards to make savings unless it is underpinned by a wider examination of the sustainability of the health model that captures how we can lead, exactly as Anthony said, healthier lives of the population have a preventative model when it is less focused on interventions at a later more expensive stage. Developing that theme a little bit is the whole question of innovation. I guess that it comes back to not just about the money but about how we do things. You cite in the report a couple of examples of innovation. One is a bit more long-standing and structural, which is the NHS 24 system that has been reviewed and reformed. I want to start by asking you about the case study that you put in the report, which is the Scottish Ambulance Service intervention. You describe it as that they have established an integrated clinical hub, which is to introduce a level of clinical judgment to determine whether or not there are calls for ambulances to attend. There is, in fact, a reasonable demand being placed upon the service or not. The finding that you came up with or the Scottish Ambulance Service supply to you was that, when there were interventions, it was discovered that up to 50 per cent of those calls did not require a 999 ambulance. I wonder whether you could reflect on that and perhaps enlighten us to the extent that you are in a position to about whether, if that was the result, a 50 per cent reduction in the requirement for 999 ambulances based on a 15 per cent intervention, if there was a greater level of intervention, if more of those calls were screened or this clinical judgment was applied to them, would that then lead to the same kind of results right across the entire service? I am going to bring colleagues in, actually, if you look at this closely. Firstly, Fiona, I will come in a second. At a strategic level, it is these types of tests of change and innovations that are so crucial to change the model of health services. Patients behave rationally, convener, as we know. If they think that they are there unwell, they will phone 999. The steps that the Scottish Ambulance Service is taking are really important. Early signs are very successful, too. The expansion of that approach across Scotland with the thorough evaluation really matters and builds upon those approaches across other aspects of healthcare, too. Fiona can start, and others can jump in, as she wishes. We had a good conversation with staff about this particular project, and of the 15 per cent of cases in which the advanced practice clinicians consult with patients, half of those are able to stop a 999 ambulance from having to go out, so that is a really positive development. Sass has done a lot of work over the last year in managing demand and capacity, so a lot of that is about trying to prevent patients who do not need to go to hospital from going to hospital, so it is about finding the most appropriate care pathway for them, and sometimes that is within the community. That work is still on-going, but the early signs are that it has been a really positive step in that direction. They have also said that they are doing a lot of work with boards and local authorities to talk about this approach and how it can be best applied within local areas, so that it is not just happening through Sass. The flow navigation centres that are part of the redesign of urgent care are all designed to help to prevent patients going to hospital when it is not necessary to find the most appropriate pathway of care for them in the community. Is this clinical hub a pilot in one particular geographical area? Or Fiona, how is that working? It is not in one particular area for Sass. The flow navigation centres that are within boards are not. There is a flow navigation centre now within every board, but the arrangements are slightly different within them. As I say, it is part of this redesign of urgent care programme that is on-going, and I think that the evaluation of that is still on-going as well, and I think that it is due to report it later this year. I am quite sure that we would be interested in keeping a close eye on that to see. Antoni, do you want to come in on that point too? I was just going to make a more general point that the health department has been very focused on unscheduled care and unplanned care. This is a very important strategic programme of work. This is one aspect of that work as well. It also ties in, I think, with some of the primary care reform activity that has been going on across the health service for some time now, and it is a question that we are going to be exploring, I think, in our future audit work on the NHS. It may be an issue that the committee wants to explore with the Government if you invite me in for evidence. One of the other areas that has been mentioned in your report is NHS 24 interventions. By the same token, how effective have they been? Are they revising the way that they work? Is there more investment going into that? We are not least in the Covid-experienced environment. The delivery of public services has been viewed slightly differently, in light of what had to happen because of circumstances over the course of the pandemic. Could you enlighten us on the NHS 24 changes or interventions and how effective they have been? I agree that we have all seen how central NHS 24 has become over the course of the past few years. We often use terms in the NHS about triage and pathways, but it is about getting patients the right care that they need in the right place and supporting their understanding of where best to go and when. Fiona is the best place to talk to the committee through that. The work with NHS 24 is at the heart of the programme that I talked about, about the redesign of urgent care. The stated aim of that is to help to reduce the number of people who self-present hospital as a first port of call by 15 to 20 per cent. The most up-to-date figures that I have seen from NHS 24 papers is that they think that, compared to 2019, there is about 11 per cent reduction in that, but that is a programme of work that is on-going and has yet to report yet. I am a bit of a bit of a caution around those figures until they are officially published. I know that when the winter pressures were at the regates this year or towards the end of last year, there was an announcement made of additional funding to recruit more people to come to work with NHS 24 and an additional 200 people to help to meet that increased demand on NHS 24. It looks like that is on target. At the moment, looking at the most up-to-date papers and board papers from NHS 24, it looks like it is going to surpass that target. We are short of time, so I think that those are areas that we will want to return to as a committee. I think that they are worthy of further examination, but time is tight, so I will ask Willie Coffey to come in who has questions on the use of agency nursing and so on. Thanks again, convener. It is about staffing, capacity and wellbeing issues, Auditor General. Your report clearly tells us again that staff numbers are at a record high, everyone is at a record high, as you have said in the NHS, but we still face this problem about workforce and recruitment and the excessive, of course, of employing bank and agency nursing staff. How do we resolve those issues? What are your views on the solution to that particular problem? Mr Coffey, our paper, as it has done in over many years, identifies just how pivotal NHS workers are to delivery of health services. We reference that there is a new NHS workforce plan, but that the system remains under significant pressure in terms of wellbeing. There is still emphasis from health professionals on the sense of burnout that NHS workers have experienced. In particular, looking at the bank and agency costs again is not a new issue. It has been around for decades about having the right access from NHS boards to the skills that it needs at the right time. Bank and agency costs have increased. There are not enough people to fill the nursing post. There have been some innovations, such as through training places with universities, and we know that the chief nursing officer is actively engaging with boards to try to come up with a longer-term solution. In terms of nursing in particular, our report also references that the reach of the NHS in Scotland has expanded internationally to try to access some of the additional skills to support services in Scotland. It has considered an interesting value for money arrangements around this and taken a view that, although there was an initial premium, the fact that the Scottish NHS has not paid for training arrangements offsets some of that cost. It is a sustainable model that is needed, in terms of the totality of a workforce plan that delivers for health and social care in Scotland. Bank and agency is one part of that. I suspect that there will always be a component of it, but it is the extent of reliance on it that matters to be tackled. I think that my colleague Sharon Dough may come in and follow recruitment and internationalisation in that aspect. In a wee minute or two, your report also talks about the wellbeing issue. Auditor General, you mentioned it there, too. The report notes the Government's view that there is not a culture of seeking help in the health and social care sector. Could you say a wee bit more about that and what role the national wellbeing hub is playing in that, because that is a very important area, because we know that absence rates are particularly high? Could you say a little bit more about that, to give us a flavour of the issue there? I am happy to start. I bring Fiona Hennigan as well, who has also looked at this part of it. Thank you. I was very struck by that sense of resilience, robustness and the need for NHS workers to seek help and support. I think that we cannot clearly be understated just by the challenge and trauma that they have experienced in dealing with Covid over the past few years. Therefore, not just for them as individuals, but really for their employer to have appropriate arrangements and to support people's health and wellbeing. There are aspects of the way that the Government is approaching this. We have talked about the phrasology that is leading to change to build stronger, more effective arrangements to support their colleagues in accessing health and wellbeing support, but also building the right sustainable conditions that will not have NHS workers operating under periods of extreme pressure for a prolonged period. Fiona can say a bit more about how that is planning and any evaluation that the Government has done. I do not have an awful lot more to add other than what the journal said. It is just to say that, when we had our case study interviews with boards, it came through loud and clear that staff wellbeing was of critical importance to them and that retention is crucial because you can recruit as many people as you like, but if you are not retaining them, you are unhiding to nothing. In paragraph 51, we talked about some of the steps that are being taken around putting in place of wellbeing coaches for staff and having people working within those teams, then trying to encourage that culture of speaking up when things are not going well for you and just trying to promote that culture from within in terms of any evaluation of that programme. No, I do not have any extra information on that at the moment. Too early to make any kind of guess as to whether those measures are effective in dealing with the whole wellbeing issue and the absence, the high turnover issue. Is it too early to say that we are making an impact? I do not have enough evidence at the moment to say how well that is working. I think that the next up-to-date data about staff absence internally will not be later until it is available to later this year, so it will be certainly worth looking at when that comes out. That is right. There needs to be evidence and data led for that evaluation, but it is also the service that the trade union and the representative bodies are undertaking and they are pretty consistent, Mr Coffey, about just how their members are feeling the pressure, the extent of burnout, the need for support, the need to ease that pressure. Even some of the examples that we have in the report about nurses reporting only 37 per cent reported able to take the breaks that they are expected to take just points to the on-going challenge that they have been experiencing. Nobody wants to experience that in their workplace. Inevitably, that will have a flow-through impact in terms of absence rates. People are deciding to make different career choices, so the wellbeing matters, but that is almost the element of reactive response. How do you ease pressure in the system? In the other examples that we have heard about NHS 24 and Scottish Ambulance, there are all components of it. Sometimes when Audit Scotland talks about a sustainable model, the inference is that it is just about a financial position. It is about sustainability across the piece for patients, but it is also just as important for those who work in the NHS. That sounds like a clear area of focus that the committee might want to concentrate on in the future. I will ask you about one of the most startling figures in the report that you are talking to this morning and where you are asking questions about. In paragraph 46, you talk about the extent to which bank nursing or nursing agency staff are now being called upon. I thought that those figures were very striking indeed. That is just in the three health board areas that you have looked at in a bit more depth. You say that the expenditure on bank nursing is up by 57 per cent in NHS Lothian, and in NHS Highland it increased by 90.5 per cent. In Ayrshire and Arran, it is up by even more than that, 90.8 per cent. Why on earth is that happening? Colleagues, you can come in and give a bit more detail behind that convener, but the numbers are startling in terms of the scale of change and call upon bank and agency numbers. They are also not sustainable in terms of delivering a financial perspective, but be in mind that the consistency of care. Health workers talk about having that familiarity relationship with patients in their care, and if that is chopping and changing through different workers, all of that will inevitably impact upon outcomes. Some of that will be driven by inflationary pressures, cost of living and the availability of staff. Particularly in some of the more rural areas, there will be a premium and just the access to external factors beyond the control of the NHS, but affordable housing plays a key part in the ability to recruit and retain permanent staff. If they are not available, therefore inevitably they will lead to a call on bank and agency nurses to backfill for those vacancies. In terms of the specifics, the numbers that Colleagues can elaborate. The only thing that I would add to that is that those figures are from 2021-22. I think that the other thing that was impacting on that was obviously the effect of the pandemic and high levels of staff absence leading to the need for bank and agency staff, as well as all the things that we have talked about in terms of vacancy rates. Obviously, again, from an audit point of view, these are people, of course, we are talking about, but as a unit cost, the unit cost of the health service of agency staff is considerably more, is it not, than the cost of a direct employee? Yes, it is. Some of that is not to say—there is no value judgment for us about agency workers relative to permanent staff, but there is a cost perspective. Yes, they will pay more. Employers will, for periodic requirements, require that flexibility. Whether it is staff absence or a planned increase in capacity, if it is the planned nature that matters most, if you are continually relying on long-term banking agency, then you are suggesting both increased costs and not the provision of care that you would want through permanent employees. As a committee, we have retained quite a strong interest in that and to see where that goes in the next financial year. Again, we are short of time, so I will bring in Bill Kidd, who has a number of questions that he wants to put. Bill? Thank you for everything so far, because it has been extremely interesting. Linked in with a number of the elements that you have been talking about, obviously, are waiting times and waiting lists. Exhibits 4 and 5 on pages 21 and 22 of the report show waiting times and waiting lists for planned care have increased and continued to grow, as has been said. 5,450 or 3.4 per cent have been waiting more than a year for a diagnostic test or investigation, so the report refers to limited progress in tackling this backlog of care and the increase in waiting times and waiting lists. Do you have any evidence of people starting to look beyond the NHS for their healthcare? We have all seen on television people saying they have gone to Eastern Europe or even further away to get through more quickly. Take your questions in reverse order for me. I do not think that we have seen anything other than anecdotal evidence of people looking to exercise other options for where they received treatment. The wider point about waiting lists and tackling backlog is one of the central planks of today's report. As there are many factors, people are still waiting longer than they would have done before the pandemic for treatment. We are calling for real clarity. We have touched on it already this morning, Mr Kidd, about across specialisms that people can have a clear expectation of how long they will have to wait for treatment. There have been some aspects of progress, especially for those who have been waiting longest for treatment and patients waiting two years and longer. They have become a priority for the NHS, so that aspect of wait times is reducing. Unfortunately for the NHS, because of the way the performance indicators are constructed, that looks like a deterioration in performance, because it is based around a certain number of weeks of treatment. If the NHS is focusing on those who have been waiting the longest, it does not tackle how that interacts with the performance indicator. Aspects of progress for the longest waits, but fundamentally from today's report from Audit Scotland, is a call for real transparency for patients across all specialisms of how long they will have to wait and if needs be an update to that part of the recovery plan? Waiting times for planned care vary significantly by speciality across and within the boards. Is it being investigated or do you think that there is any scope for more collaborative working across and within health boards to reduce these waiting times? Is it possible that the health boards could co-operate because it is longer waiting list in one and it is none other for certain treatments? If I may start on this action, I will bring Fiona in, just to say about how that is working in individual board levels. One of the key planks of the Government's plan to tackle waiting lists are the creation and expansion of the national treatment centres to boost capacity to tackle many of the waiting times. We touched on our report and it has been reported since that there are challenges in the delivery of some of the national treatment centres, I should say, both in terms of cost growth and timing. We are suggesting again that there is clear on-going communication around the delivery of the treatment centres. We touched on in today's report also that the national treatment centres are looked to be geography blind if I can use that expression, that they are a national resource. I think that it is helpful that the Government has clarified that it is not designed regardless of where it is positioned in the country that patients from across Scotland have uniform access to those services, but Fiona can come in and say a bit more, Mr Kidd, about how boards are working together. In our case study interviews, we definitely found some good examples of boards working together locally, regionally and nationally to try to offer mutual aid and share good practice. As the auditor general said, one of the ideas behind the national treatment centres is that we should not get these hotspots that some of that capacity can be shared across the country, so that, hopefully, areas where we have a particularly high waiting list that can be resolved more quickly—for example, Glasgow, if you have a very high waiting list there and it is much lower elsewhere—you might be able to move people around a little bit if they are willing to travel. The centre for sustainable delivery is a new unit that was set up earlier on in 2021, and all the boards mentioned the work that they are doing is helping them greatly to work together and share best practice and help to work together to reduce waiting lists. The other thing that I would say is that additional waiting list data has come out since we published, and it shows that, for outpatients and inpatients, there is still an increase in that waiting list, although the rate of growth has begun to slow. For the first time in the long time, it has started to see the size of that waiting list, particularly for radiology, starting to decrease slightly. The only thing that I would say that would temper that slightly with the winter pressures, with some boards having to pause some of their elective and planned care again, is that we are not sure what impact that might have when we see the figures for the next quarter. Thank you for that. That is an interesting point. I should go for a minor tangent, but it is still linked. Patients, obviously, when they have been removed from the waiting list when they have attended their appointment, have been admitted for treatment, so they are not on the list anymore. If the treatment is no longer required for patients for whatever reason, you would imagine that they are not on the list any more, hopefully. Is there any data for the number of patients removed from waiting lists due to no longer requiring treatment? Is there any trends that can be identified? Yes, some data does exist about patient no longer requiring required treatment. I do not have a further breakdown within that to say what the particular reasons are within that, so there could be a number of reasons they decide not to go ahead with it, or they, for example, decide to go down the private healthcare route. To be honest, I have not looked at those trends in any great detail. There was nothing hugely that jumped out to me when I looked at it, but data does exist on that yet. The impact of increased waiting times on people's physical and mental wellbeing can be highlighted in evidence that patients are presenting for care in a worse condition than prior to the pandemic. The report states that no longer waiting times are impacting on patients and people's health and wellbeing, with patients presenting for care in a frailer and more acute condition and with more complex needs. Are there assessments being made of the impact on current waiting times on health and wellbeing of the patient prior to their attendance in hospital? I have a question that we talked specifically about that assessment, but what I can say is that from our case study interviews, they all said without a doubt that they were seeing cases of people presenting in a much freeler condition than before the pandemic. We also had a good conversation with them versus arthritis, particularly around some of the patients that they are supporting as well, and they said that they were seeing an impact on the way that it lengthens on people in terms of their independence and their pain levels and their physical and mental health. There is information from a survey that versus arthritis did back in 2020. I do not have those particular figures with me, but I did show most respondents the increased levels of pain, reduced mobility, independence, deterioration and physical and mental health while waiting for treatment. There are figures around that. That is really helpful. Thank you very much for that. We also touched on the report on the excess death analysis as a result of the pandemic. The national data is inconclusive in terms of whether excess wait times are a key contributor to excess deaths at this stage. We have also seen the Government being clear with people about some of the things to look out for that the NHS is open. In spite of the circumstances, deaths did arise over the course of winter pressures, when some urgent situations resulted in delays to planned treatment, but the totality of the message is that the NHS is open if you have conditions or symptoms to seek treatment, rather than referencing back to where we were two plus years ago about easing off access of services. That is a public information announcement by the Auditor General. Excellent. Craig, how do you want to come in on this area? Mr Boyle, you made reference to the private sector and the anecdotal evidence that you suggested. Obviously, I think that it was a BBC disclosure programme. Again, it was a survey, so we cannot necessarily put a lot of store on it, but it found that one in five people on NHS waiting lists had some contact with the private sector over the last 12 months. I think that that puts something broadly off of that order. Is it worth interrogating perhaps the size and the use of the private sector at the moment? Wouldn't that obviously have a read-through in relation to some of the pressures that we see within the NHS? I am thinking particularly, and again anecdotally, in relation to my post-bac and probably colleagues' post-bac treatment, for example, orthopedics or early stage cataracts. Many people only have their first clinical appointment, in effect, when they are told that, despite the fact that they are saying that the NHS is open, that it will take three to five years for that treatment and that they are automatically pivoting to the private sector if they can afford it, which obviously undermines fundamental principles of the NHS. However, I am just concerned that you may see staff drifting towards the private sector if there is a growth in those specialisms and that people are electing to do that. Although it may bring down waiting lists in some senses, it also means that those with the means to do it or the borrowing capacity to do it will be accessing healthcare far quicker and therefore not reaching the same levels of acuity for those who would not necessarily be able to do it. Is it worth in terms of taking stock of the private sector if there has been some shift because it would undoubtedly, at some point, have an issue in relation to any CHISC capacity, both workforce and waiting list capacity? I think carefully about what that means for our work and the boundaries of our responsibilities as it relates to public spending. Yes, we are interested in the use of health services, whether it is the growth of national treatment centres or the extent to which alternative arrangements from the NHS lead back through its self-accessing private providers to tackle, as it has done in the past, to tackle waiting times. Like you, Mr Wilding, I have only anecdotal evidence at the moment that people are exercising this choice. We will keep an eye on it, I think probably, but as much as I could say through surveys, analysis and data, and perhaps more pertinently, that few others suggested about, if that is leading to any tangible, noticeable change in patterns about the size of waiting lists, there is a discernible judgment that we can reach from that. We will build that into our thinking as much as I would say at the moment for next year's overview report. Thank you. We have mentioned a few times this morning the national treatment centres, which are in part a national health service response to some of those pressures in place of the private sector. We know that there were three national treatment centres scheduled to open up last year and they did not. I think that the last time I saw them, they were scheduled to open up in the first half of this year. Rumour has it that the First Minister in one of her final acts may be opening one up before the end of this week, whether that is true or not, remains to be seen. My serious point is that there have been delays. Can you elaborate for us your understanding of the reason why there was a delay in the opening of the treatment centres? That has contributed to the pressures that we have been talking about for the last hour and 20 minutes. Do you have any updates that you could give us as to whether they are on schedule to be opened up during the course of this year? I will bring Lee in, convener, to share what we have. Some of the announcement of delays was made after our publication of our work, so there is perhaps a bit of an overlap there. Before passing to Lee, the most important thing is just how important the national treatment centres are to building the capacity. Ten of them are planned across Scotland at 40,000 procedures by 2028. We know that all those delays will push likely some of the required capacity towards the end of this decade. I am not sure whether I have the detail to be more specific about that, but I will turn to colleagues if we can update the committee as best we can. As far as we are aware, the three that are due to open are well open over the next couple of months. That is the latest information that we have. I think that there have been a number of factors at play. Obviously, some of them were already in train when the pandemic hit. There have also been issues around the fact that other sectors are being impacted in terms of availability of both construction materials but also the cost of construction. Another challenge is obviously staffing those new centres and making sure that the staff that are needed are in place. There are key staff that are needed for those centres that are notoriously difficult to recruit anyway, for example theatre nurses and ethotists. It is a combination of factors that have led to those delays. As far as we are aware, the three of those will be opening in the next couple of months. Again, that is something else that will add to our list of watching briefs that we will need to keep an eye on as a committee. I have one more question before I draw to a close. I bring in Sharon Dow in Bill Kidd and Willie Coffey for one last go each. What I was interested in just to tease out was that in July 2022 it was announced that there would be new national planned care treatment targets. As I understand it, the deadline for some of those targets has already passed with them not being met. Are you aware of the targets now being reviewed and do you know what the new targets and time skills are going to be? Fiona Hyslop has that detail. I was not aware of any of those targets being reviewed or revised. You are right in saying that some of those deadlines have passed. Substantial progress has been made in reducing some long waits. It looks like the targets, depending on how you define the target, have not been hit. I would be very interested to see whether they are planning to revise those targets, particularly in light of some of the policies and elective care that we saw at the start of the year. I am sure that we will return to those issues in subsequent sessions to talk about the NHS. Sharon Dow has a final question to put from her before I invite Bill Kidd and Willie Coffey to come in. The report highlights workforce capacity as the biggest risk for recovery and shows that one key recruitment target of increasing the GP workforce by 800 is not in track to be achieved by the deadline of 2027. What is the Scottish Government doing to address that? In your view, is the target still achievable? At a high level, I am absolutely right. A sustainable workforce is such a fundamental to delivering the recovery of the NHS and the sustainable service. I will bring Lee in in a second to update on the GP delivery target. What we have said in today's report is that we are raising a red flag that progress towards the delivery of 800 GP targets is at risk and that the Government's plans and the steps that they need to take are fundamental. It relates back to shifting the balance of care from an acute setting into primary care and a preventative context. Before passing to Lee, I am happy to say more to the committee next week that we are giving a bit of thought to future audit work in this area and potentially doing audit work on primary care services that can track and report further on the progress towards this aspect of workforce in terms of GP numbers. Lee can say a bit more about what that is looking like at the moment. In terms of what the Scottish Government is trying to increase training places to encourage people to pursue a career in general practice, it is a challenging target, although there is no getting away from that. I think that there is a range of other things that they are also focused on in terms of retention of our GPs. Our GPs are also very stressed and burnt out following the pandemic. There is huge demand on them, so it is about how we retain the GPs that we currently have. There are a number of reforms in progress, one of the main things being the multidisciplinary teams to try and reduce the workload on some of our general practitioners. However, as I said, it is a challenging target. As our report says, we do not think that it is currently on track. Is there enough conversations between the Government departments when they make these announcements? The lights have announced that we are going to have 800 extra GPs, but are they speaking to universities? Are they giving them the funding? We hear that Scottish universities are limiting the number of Scottish students that can go in because they need fee-paying students to go in to pay the costs. Is there enough funding being given for those places? When you spoke about the primary care workers, they are obviously trying to put more pharmacists in to help GPs and take off the workload, but then I will hear stories about the pharmacists going in and the GPs then reducing the number of hours that they are working because they are burnt out. It is not actually helping, but there is also an issue with the workforce planning for the pharmacists. Is there enough funding being given to the universities to make sure that we can get Scottish students' places? We did not look at the funding in any detail in terms of what is being given to it. We did not find any evidence that the universities do not have the capacity to offer the additional training places that the Scottish Government is planning. One of the things that we have come across that we outline in our report is that there are pressures on supervision, because, obviously, when the trainees come through and go into general practice, they need to be supervised for a period of time. We are aware that there is some pressure on the number of GPs, for example, that are allowed to supervise trainees. NHS Education Scotland is obviously looking into how it can improve that situation and address that pressure, but we did not look at the funding in any detail. It is part of the plan in terms of not just a notional target of 800, but clearly there has to be people who are brought into those roles. That is absolutely part of the funding through university. Not just for GPs, but our report also talks about funding for nursing vacancies and the role in the work that they are doing with universities and colleges to support that. The other organisation that has a key part to play this is NHS Education Scotland's role in supporting trainee doctors through to qualification and practising. That brings us back to the needs to be a co-ordinated, detailed plan to deliver on those targets. That will be the route through to tackling some of the challenges that are set out in today's report. Following on in terms of recruitment in the report, paragraph 111, in page 37, the Scottish Government's shot to medium-term strategy is investigated in mitigating the domestic supply of staff with international recruitment and £1 million provided to each board to help to identify international staff who can complete the training, etc. Now, you have targeted three boards and each of those does show have recruited internationally. It also notes that NHS Highland found the process of time-consuming and expensive. Can I ask if this represents a suitable option for future NHS workforce growth? I don't think that we've reached a view on whether it's a suitable or best option. I think that it's likely to be a question that the NHS can best explore what their longer term strategy is. It feels like it's a part of a number of steps, a number of tools that they have at their disposal to tackle a short-term issue. You can see that there are some aspects of progress, some successes in it, the cost benefit of going down this road relative to recruiting and training domestic workforce supply all needs to be evaluated. I think that it's one of many aspects, but it shouldn't be seen as a very clear direct alternative to longer term training as part of a co-ordinated workforce plan. Does that mean that you can't do just one or the other? Do you have to build it as a programme forward? My sense would be a small component of recruitment into the NHS. It's a necessary reactive step to bring in capacity when it was most needed during the pandemic and the aftermath that we're now in. It doesn't feel like it's a long-term key workforce planning for the NHS. I should say that we've not done any detailed work on this yet, but it feels like our interests have been a much wider evaluation of how NHS workforce is operating. The final question in this morning's session goes to Willie Coffey. One of the huge issues that we've seen over the years, and it dates back to Bob Black's time, was about how the Government, the NHS, engages with the public in the reform process, the journey of reform and how we engage and get the support of the wider public. I was visiting one of my own GP practices in Comarlar recently, and there were about 20 or so of GPs who had some time to talk to me about this issue. They're concerned and disappointed that the public perception of them is that they're not working for them and willing to see them. That's a big issue. All the members have heard this right throughout the Parliament, but it's not true that GPs are delivering these services, they're engaging with the public face-to-face. However, the public perception issue is a big issue for us. Could you offer any advice to the committee about how the Government could revisit this problem and have a closer engagement with the public to allow them to make this journey of reforms along with us? Very interesting example, Mr Coffey. My predecessors, Bob Black, Karen Gardner and myself, have all said that the sustainability of the NHS in Scotland needs detailed evaluation and engagement with decision makers and parliamentarians, such as yourself, people who work in the NHS, but most fundamentally people who use the service patients. That's not yet happened in a really detailed national conversation about the sustainability of health and social care services. Not just us, but many people have said that we're not in a place that we have a sustainable model that can work for all of us in terms of what it costs, recruiting people to work in health and social care and delivering long-term preventative better outcomes for the people of Scotland. We have to do that. We have to engage the public about their expectations and what is achievable. It's a key part of today's report, one of our recommendations, Mr Coffey, that that step now needs to happen. That might be challenging, might involve some changes to really deeply held convictions about health and social care operates in Scotland, but we only need to look at what we're experiencing over the past few years about a system that feels fragile, and to layer in some of the views of the Scottish Fiscal Commission experts that, if we continue on the path without making some of those reforms, it will require very unpalatable choices about prioritisation. If we continue to invest in health and social care services in the way that we're doing, it will mean that we won't be able to afford other key parts of public services. All that requires a detailed, structured conversation, but fundamentally with the public, so that they can have their voice and what matters to them. Have you used how we should deliver that? What kind of participation processes should we try to create to promote, to really and truly engage the public in this reform process that we all know is needed? How do we go about it? Saying that it's needed is great, but how do we deliver any suggestions that it could offer us? You're right. It's easy to say it. I'll probably reserve a chance to comment on that. First, I have a question for the Government and the NHS. Do they agree that that's what's necessary and how best to do that? I think that there's also a role for the Parliament, if it should. I'm thinking about how we are measuring the performance of the NHS in Scotland. Do the performance indicators that we currently use on and report so regularly, are they giving a good enough story about how healthy Scotland is as a country? I think that that's equally part of it to Mr Coffey, but how do we best go about that? I think that there are people better placed than I to say that the most effective way of public engagement, that's clear from our report, is that that needs to happen next. Thank you very much indeed. I guess my take from that is that we can't rely on a top-down solution. There needs to be a proper participatory engagement of people if there is going to be any faith placed in any reforms that take place. I want to really thank you so much for the evidence that you've given to us this morning. As I said at the start, it was an impactful report when it was published and I think it will continue to resonate and certainly give us as a committee quite a number of areas that we will want to pursue to get to where we think public interest needs to get to on where those reforms are, what's happening with the money that's going into the NHS and whether the outcomes are being delivered and if they are not, why not and what can be done to fix that. I'm going to thank you very much for your contributions this morning, thank the committee for their questioning and I'm going to move the meeting into private session.