 Good morning and welcome to our 23rd meeting of 2023. I have received no apologies for today's meeting. Today we have a session with the cabinet secretary for NHS recovery, health and social care, further to a recent scrutiny of front line NHS boards. I welcome the cabinet secretary to the session. We have Michael Matheson, cabinet secretary for NHS recovery, health and social care, John Burns, chief operating officer from NHS Scotland, Stephen Lee Ross, deputy director of health workforce, Scottish Government and Richard McAllum, director of health finance and governance in the Scottish Government. I invite the cabinet secretary to make a brief opening statement. Good morning, convener, and thank you for inviting me to meet with the committee this morning, which is my first appearance since I was appointed as the cabinet secretary for health. I welcome the opportunity to engage with the committee and I look forward to discussing a range of vital issues in the weeks and months ahead as the recovery and renewal of the NHS and social care services continues. I thank NHS boards for continuing to provide information to the committee, which has been taking evidence about their performance in recent weeks. Ministers and Scottish Government officials regularly meet with representatives of all health boards to discuss matters of importance to local people. It is my strong belief that the Scottish Government should not only fund, empower and enable boards to make the decisions that they feel are most appropriate to their locality and their board area. We acknowledge the pressures felt by boards across the country as we all continue to deal with the aftermath of the biggest shock that NHS system has felt since its establishment some 75 years ago. We continue to prioritise investment in front-line services, providing an increase of some £730 million for NHS boards through the 2023-24 budget and an additional £200 million in-year support above initial plans to support the financial sustainability of NHS boards. That means that no board is more than 0.6 per cent from Enrack parity. In addition, we continue to provide constant support and guidance to NHS boards to ensure that they are doing everything that they can to provide the best possible care for people in their localities. Our new prospectus for the year ahead demonstrates that this collaboration is a key part of our plan to deliver year-on-year reductions in wearing lists, delivering additional capacity through our national treatment centres in NHS Highland, in NHS Fife, NHS Forfally and NHS Golden Jubilee. Another good example would be the work done to increase workforce through the hiring of additional £800 staff from overseas, helped by £8 million of funding in October last year. We set ambitious targets to recruit some 750 additional nurses, midwives and allied health professionals from overseas, and I am pleased that, due to the hard work of health boards, we have exceeded that target. That is the kind of joint working between central government and local boards, which I hope will go from strength to strength as we go forward. I am happy to respond to any questions that the committee may have. We are going to move straight to questions, and I am going to move to Evelyn Tweed. We know that older people enjoy generally better health than the predecessors of an equivalent age, but we also know that they still have significant health needs and multiple health needs. What is the Scottish Government doing to look at that demand and those health needs? If you look at the burden of disease over the years ahead, that is going to continue to increase over the course of the next 20 years. The burden of disease will increase by something in the region of around 21 per cent. The large part of that is because of the demographic shift that we are experiencing as people get older. The number of things that we need to do in order to tackle the burden of disease is to make sure that we are taking forward all the right preventative measures to help to reduce the impact that lifestyle options can have on someone's health, so all the public health measures that we take forward to help to improve people's health is important. The second aspect is to make sure that we are doing everything that we can to tackle the social inequalities that drive health inequality, so tackling poverty, reducing child poverty, all of those factors are all key parts to helping to ensure that we have a focus on preventing ill health due to social inequality. The third thing is to make sure that we are continuing to develop and adapt our services to meet that increasing demand from older people and from people who have got multiple conditions to make sure that we are managing the long-term conditions effectively and to do so in a way that helps to not only improve their health but also allows the health services to be sustainable. Prevention is critical but also making sure that we are adapting our services to meet that increasing demand that we are going to face as our population gets older. That is also about making sure that we have effective integration between our health and social care services given that they are critical to one another in helping to support particularly older people in managing at home with the support and assistance that they require. We know that rural and island health boards are experiencing significant challenges because of demographic shifts and they are having particular difficulties filling vacancies. How will the Government ensure that those boards are supported to make sure that this urban rural divide does not become a thing and that we make sure that those inequalities do not come to pass? I will probably bring John Burns in here at some point to say a bit more about some of the work that we do. If you look at the challenges that rural boards face in particular, they can experience difficulty in recruiting specialist staff into them because of the numbers of patients that they are dealing with in particular departments. They are not as attractive to the recruitment of staff into them. There are a number of reasons for that. One of the things that has been happening for some time now is the ever-increasing specialisation of clinical care. Moving away from being much more provided on a general basis, the general physicians that we had much more of in the past are less and less becoming more and more specialised. Part of that has driven a behaviour that results in clinicians wanting to work in centres where there is much more throughput in specialist centres in order to see the range of patients that they are looking for and also to build up experience, etc. That is much more challenging for rural boards given that population levels are much smaller and that they are not able to sustain the same services. For quite a number of years now, we have been putting in place arrangements around managed clinical networks where we are able to use clinicians in some of our bigger centres to provide clinical support to boards in our rural and remote areas. Sometimes that involves going out and holding clinics in those areas. Sometimes it is about helping to support clinicians in those areas and supporting the decision making and reviewing patients. That is one of the ways in which we try to help to support some of those rural boards in our island boards to be able to help to sustain and support services. Sometimes it does mean that patients have to come into some of the larger clinical centres for particular specialist care and specialist intervention. John, can you say a bit more about some of what we have been doing in that? That has been an on-going piece of work for some time now. Thanks, cabinet secretary. Maybe just a couple of points to add to the cabinet secretary's comments. Firstly, I am very struck when I visit our island in rural communities and boards that they really are at the forefront of looking to innovate and work differently and bring new ways of delivering service to their communities. I think that the importance of collaboration, regional working and networking building that critical mass of service, but also using technology and new ways to deliver those services. Again, I have seen some very good examples across particular island boards where they are collaborating not just in their natural, regional, north-east but across Scotland. That shows the strength of the use of technology and the ability that the new ways of delivering services bring. The other thing that I would add just finally is that rural and island boards are also at the forefront of looking at new roles, scaling up staff to take on enhanced roles or advanced roles. That is helping to deliver services in their communities and across their populations. The Scottish Government's report on Scotland for the future opportunities and challenges of Scotland's changing population highlights that an ageing population with an increasing number of our oldest old citizens has the potential to transform our population health and care needs. That is particularly prevalent for islands. My question is what the Scottish Government is doing to address the issue of population decline in parts of our rural Scotland and islands and how that particularly feeds into recruitment issues around that. Do you mean in terms of trying to reverse depopulation in rural and remote areas? You will be aware that there is a range of work that we take forward to try to help to make rural and island areas attractive locations. Whether it be addressing issues around digital connectivity or economic activity to make it a viable place for communities to thrive and to grow, there are all measures that we try to take forward to help to support people in living in those areas. Take for example aspects such as the islands growth deal, the Argyll and Bute growth deal. All of which were about helping to help to reverse issues around depopulation, putting in infrastructure to help to make those communities attractive and to encourage people to live in those areas. When I was the Minister who was responsible for taking forward growth deals, a key part of what we were trying to do with them in working partnership with local government in those areas was to try to put in measures that we knew that would help to support communities that were already there but also to help to make them attractive communities for people to go and live in. One of the big areas, big issues that was often flagged up to me was issues around digital connectivity. The ability for people to live in rural and island communities and to be able to work from home or to have a business-based in those areas led into a big part of the DDR programme, the digital superfast broadband programme, which was all about helping to support rural communities to make them attractive locations and to have infrastructure in place to help to support them. That is the measures that go well beyond my portfolio idea. That is the measures that the Government takes in a broad base economically to try to help to make our rural and island communities attractive locations for people to continue to stay and live in. Good morning, cabinet secretary. Good morning, everybody. It is just to pick up on that issue. Health is not the only portfolio that needs to address the issues that we face when it comes to populating and everything. I would be interested to hear how the Government is working with other portfolios such as housing, because I know that the cabinet secretary for rural is working with Paul MacLennan for housing to look at supporting that way. Is that kind of work that is taken forward in cross-portfolio engagement that is also necessary? Yes, but there is no single action that you would take that will help to address issues around population shift and to make our rural and island communities attractive for people to live and work. It has got to be a range of different actions, so you will be aware of some of the actions that have been taken in some rural areas around things such as housing and some of the measures that we are planning to take in order to help to free up capacity around housing in our rural and island areas. It is a combination of factors—transport infrastructure, housing, digital infrastructure, good quality health services, sustainable health services in those areas, access to education. All of those have a key role to play in helping to make our rural and island communities attractive places for people to live and stay. They cut across all parts of government portfolio, and I know that some of the work that we are taking forward in government is about trying to make sure that there is a consistent approach in how we deliver those things and that we are all prioritising them. I am now going to move on to our next theme, and Tess White. Thank you, Goodmina. Good morning, Cabinet Secretary and panel. Cabinet Secretary, the chief executive of NHS Grampian told this committee that the health board would still be in deficit by 2028. That means that NHS Grampian, like many of the health boards, will have very difficult decisions to make to plug the holes. Please, what action is the Scottish Government taking to support the financial sustainability of health boards in the short, medium term? You will be aware from your inquiry that the way in which funding is allocated to health boards is through the NRAC formula, and the way in which it is distributed in the basis of looking at population share, geography and deprivation factors that are all taken into account, and the funding is distributed on that basis. That approach has been taken for some time now, and it continues to be taken forward. What we also do is provide tailored support to individual boards where there are issues that arise financially for them in year, where they require financial support. That has been the case historically as well. In the short term, where NHS Grampian requires additional financial support, we will look to try and provide them with that where we can and where there is the funding available to do so. Briefly, we will try to make sure that we continue to make progress with the use of NRAC formula. I know that NHS Grampian raised that issue for them in terms of parity. I mentioned that we have already provided our £200 million in this financial year to try to help to close that gap yet further. We will continue to try to do that as we go forward in the medium term as well. That combination of short term, tailored support alongside continuing to move towards NRAC parity, is the way in which we would try to manage those issues for a board like NHS Grampian. One of the issues that was raised from just about every health board that the committee met was about the cost and use of locum staff, and particularly some of our island board, some of the fees that they were looking at to engage locum consultants were quite eye-watering. We heard for a year up to about £3 million. It was one figure that was quoted. If you could tell us what action the Scottish Government is doing to help to reduce the reliance on locum staff and agency staff and shifting that more towards making the NHS more attractive place to be a permanent member of staff? You are aware that NHS Scotland, as is NHS across the UK, has used agency staff at various points. What has happened over the course of the last year, if you look at the figures, is that in the past 12 months there has been a bit of a spike in the amount of agency staff that have been used. It is largely a reflection of some of the significant challenges that the NHS has been facing during the course of the pandemic and some of the recruitment challenges that they have faced, which has resulted in them making greater use of agency staff. We have applied some additional restrictions to them in the course of the last month in order to reduce our agency spend. It is worth just in context that our agency spend for our budget overall is relatively small—I think that it is less than 2 per cent of our budget overall, so it is still a small portion of it. We prefer much more to be if there is a need for flexibility around staff to be working with NHS bank staff as well who are on NHS contracts, NHS terms and conditions, and we have applied some restrictions to boards to make sure that they are focusing much more on using bank staff where necessary. The other aspect to this is about making sure that NHS is an attractive place for staff to want to work, which is why the agenda for change settlement was a critical element of taking forward measures to address issues around paying conditions in order to help to ensure that NHS Scotland has seen as being an attractive place to work and to take your career forward in. Also, it is a work that we are taking forward for example around aspects such as the nursing and midwifery task force to help to look at how we can improve recruitment and retention within NHS Scotland. It is all areas of work that are about helping to try to retain staff within the NHS and also to make it an attractive place to come and work in as well, but also to look at new routes for how people can come into the regulated professions as well. That combination of reform around workforce training and planning alongside paying conditions and having much more of a focus on the use of NHS bank rather than that of agency at all, part of the package of measures that we are taking forward to try to help to reduce or depend on both low-command agency work. Another issue that was raised by several health boards was about inflation and in particular PFI costs. Are you able to tell us what impact the current rate of inflation is having on public, private partnership, public finance initiative payments and the impact that that is having on NHS budgets? Obviously, inflation is having an impact on NHS across a whole range of different areas. From the procurement of food through to drugs through to equipment through to maintenance costs, all areas of the NHS are by and large impacted by inflation costs alongside energy costs that are having an impact. That is placing a very significant strain on NHS budgets as a result. I might get richer to say a bit more about PFI and the inflation impact of some of that, but it is having a significant impact across a whole range of areas with PFI in itself within health and social care. Just two points on the PFI position. It is impacting boards and the inflationary impacts of how the PFI deals were structured when they were initially set up means that there is a cost associated with that rising inflation and it particularly is impacting those boards where they have perhaps quite a large PFI within a fairly small health board setting, so 4th Valley might be an example or an HS5. There are two things particularly that we are doing and we are working closely with the boards on—the reality is that there is a contract in place and that needs to be honoured. However, the contract management of those PFI arrangements is really important and through NHS assure, within NSS we are working closely particularly with those boards that do have PFI arrangements to make sure that we are maximising the value from the contracts that are in place. The second thing to say is actually just recognising that some of the early PFI's will at some point in the not-too-distant future be coming to an end and some of the work that we are now doing with boards is planning beyond the life of those PFI arrangements. We can give further updates on that in due course as that plays out over the next few years. That would be helpful for the committee to hear. I believe that Karen Walkins has got a supplementary on that. My point relates to all the points. A quote from Claire Burden in my own area is important. She said that she inherited a deficit of £26 million when she entered and that 2023-24 her underlying position is one of deteriorating. I just wondered whether the cabinet secretary feels that decisions or lack of decisions by your predecessor is causing on-going problems for the boards and whether you can demonstrate to us how you might treat some of the decisions that need to be made with some urgency because I think the feeling from the boards was that it was acknowledged what the situation was but there was no urgency around decision making that might help in the long term. I am surprised at that because that is not the feedback that I get from boards when I talked to them about the financial challenges that we have. They would readily acknowledge that we are aware of the very significant pressures that they are under. I am surprised that some have given you that impression. They recognise that you see that there are difficulties but sometimes there does not appear to be any urgency with decision making around how we might resolve some of it. I think that there is something that you mean but in terms of providing more money, do you mean? Let's take somewhere—is it Fife? Yes, yes, yes. Is it Ayrshire? Ayrshire, sorry, Ayrshire. So if you would take somewhere Ayrshire, we would provide them with tailed financial support because of some of the pressures that they are facing. If you were to say is it because my predecessor didn't make decisions in X, Y or Z, my predecessor gave a commitment to increasing health spending in his parliamentary term by 20 per cent. We are well ahead in that. We are making well ahead of trajectory and where we should be at. So actually the level of investment that we have put in or was put in decisions were made by my predecessor of actually saw an increase in the level of funding going into health ahead of what was actually planned. So we are actually ahead of where we should be at in that. I think one demonstrates a determination to try to provide as much financial support as possible, but I also think that demonstrates an urgency in the action that has been taken in providing additional finance to our boards. For example, in this financial year, an additional £730 million alongside a further £200 million of support. So none of that, in my view, would demonstrate a lack of urgency or a lack of understanding or a lack of leadership in trying to do what you can. However, our health service is experiencing the same challenges that other parts of the public sector are experiencing. That is that we are going through a period of austerity, which is having a direct impact on the Scottish Government's budget. We are also going through a period where we are experiencing very significant increase in costs associated with running public services because of inflation and the impact that it has on public services, all of which are having an impact on our budget. The other bit that is worth not losing sight of is that we are still dealing with the consequences of the pandemic, which means that there are still costs associated with Covid-19. However, Barnett consequentials for Covid-19 stopped, so we are having to meet that from core budgets now. A combination of extra money that is being provided, where it is available, doing it earlier and quicker, shows urgency, alongside the fact that we are also having to deal with a whole range of additional cost pressures that are having a significant impact, not just on health but across the public sector and society as a whole. Household budgets are experiencing it. Are you quite confident that you have a plan with urgency that will help them even further than the provision of funding? I am absolutely confident that we will do everything that we can. However, I will not sit here and say that all financial challenges in NHS Scotland or in the public sector will be magic to where that will not happen. We are going through a period of austerity in public finances across the whole of the UK that is having an impact on our budget, which means that we have to try to manage the finances as efficiently and effectively as possible. However, you can be absolutely assured that we will do everything that we can to try to provide the financial support where possible, but that is within the limits of what we have available to us in order to invest in our health service and other public services. I think that in Scotland, nurses get paid 6 per cent more than their counterparts, like a band 5, band 6, than in England. In Dofries and Galloway, we saw nurses for Carlyle relocate to Scotland, but we saw the opposite with social care workforce that they would be trained in Scotland in Dofries and Galloway and then moved to England. I am interested to know about, as part of the development of a national care service, improving terms and conditions for social care staff. Would that be an aim so that we could have an equivalency to retain our social care staff in Scotland, for instance, because right now it seems that staff are leaving Scotland to go to England because they have improved salary in terms and conditions? Some of that is geographically specific to your part of the world. For example, one of the challenges that we have around social care within my area is staff from social care going into areas such as healthcare, because we are highly paid for them instead. I think that part of the challenge here is that the social care workforce has been less valued than our healthcare workforce. It is reflected in the rate of pay that has historically been the case. We have to try to address that. Part of the purpose of providing additional funding to local authorities to help to support increasing pay for social care staff is to try to help to stem some of that loss of staff from social care into healthcare and other areas of employment in which they can get a higher rate of pay. We have set out a commitment to look at aiming for £12 an hour over a period of time. We are doing some work around what that timeframe will look like. The other part that we need to do here is to try to help to provide good career pathways for those who work within the social care setting, so an opportunity for them to progress their career and to move into other parts of the care setting. For example, someone with considerable social care experience might be interested in going and doing nursing, but he might not necessarily have the academic qualifications that get them into the university place in order to go and do their nursing degree. One of the things that we are looking at is aspects such as the nursing apprenticeship. Again, this is work that we are taking forward through the nursing and midwifery task forces to look at how we can create pathways into areas such as nursing for people from social care to see that there is a very clear pathway for them to go through and to try to make the social care setting appear as a much more attractive professional setting for staff to be based, but there is no doubt that my view is that pay is a big part of that and we will do what we can to try to help to address some of that because historically relative value is that social care has been paid less than healthcare and that has resulted in what has been challenges around the social care workforce. I probably should remind everybody that I am a former NHS D&G employee and I am still a registered nurse. I should have said that at the start. Thank you. We are going to move on to our next theme of redesign and Sandesh Gulhane has some questions on this. Thank you, convener. Emma Harper has started. I should have said at the start that I am a practicing NHS GP. We have a worldwide issue when it comes to medicine. We have shortages of all kinds of medicines at the moment. The biggest one that I keep facing in my practice is dihydrocodion and paracetamol together. What are we doing to try to create a smoother path for medicines, especially when it comes to the way that we prescribe and what happens in pharmacies if there is a shortage? You will be aware better than I is that whether there are shortages of particular labelled medication if there are alternatives, we try to encourage to use the use of alternative, prescribing alternative medications that might have the same purpose but may not be the type of prescribed medication that person had previously been on. I do not know where John Burns can say a bit more in terms of some aspects around prescribing. I know that we try to work very closely with the pharmaceutical industry to try to help to smooth out issues around procurement of medication and the availability of medication. Sometimes the challenges that we face are, as you rightly say, not to procure purely to Scotland or to the UK. It can be as a result of a worldwide shortage of challenges. Some of that will be around stoppiling some aspects of medications. For example, there have been occasions in recent times where there were—I cannot remember the exact medications that were before I was in health, but I remember that there were some aspects around certain medications that were concerned about access to certain forms of antibiotics. I can remember being involved in hearing a discussion where the chief pharmacist was looking at procuring some of those medications in advance so that we could hold some of them in reserve if necessary. I think that combination of trying to plan around procurement of the medication and also where there are concerns around supply chain issues about trying to stoppile some of those medications where that is possible. It is not always possible for all drugs to give some of them a short life span, shelf span, but trying to manage those things as best we can within the structures that we have through procurement and through the clinical advisers around procurement to stoppiling of medication would seem to be the most appropriate way in which to try to address it. With redesign, one of the biggest issues that I face in my practice is when it comes to repeat prescriptions and we do not have electronic prescribing yet. When do you expect this to happen? I think that there is quite a bit of work going on around this at the present time. John, you could say a bit more about electronic prescribing, but I know that there are some of the new IT infrastructure that has been rolled out for GP practices. There are about 30 or 40 practices. I have some of the new IT system in place that will help to facilitate that. That is due to be rolled out over the course of the next couple of years, which will allow us to mount much more towards electronic prescribing to reduce some of that burden. I think that IT infrastructure is key to helping to facilitate that. The new GP IT system is designed with a view to being able to provide much more around electronic prescribing. John, can you say a bit more? I have not got a lot of detail on it and I am happy to get more information and provide it to the committee. However, as the cabinet secretary has said, the introduction of the new GP IT system will be an important part of improving that IT infrastructure and recognising the point that you have made about the importance of electronic prescribing and the relationship between general practice and community pharmacy. However, rather than stray from the detail, I will ask my colleagues to provide a briefing on that for the committee. When it comes to redesign, there is little point in doing a redesign when the public do not know what is going on and how to access. What will the Government do to ensure that we have an NHS that serves the priorities of the people, but also that they know the way to access it? You raised an important point. If you look at some of the challenges that particularly the services that have been experienced in recent times, a big part has been about managing public expectation of services that are available and the most appropriate route to access services, whether it be at a primary care or a secondary care level. We have set out a commitment to taking forward the national conversation. Part of that is a national conversation to look at the design and provision of healthcare services going forward into the future and how people make access of healthcare services when it is appropriate to make a GP appointment, when it is appropriate to see a pharmacist, a community pharmacist, when it might be more appropriate not to necessarily see a GP but to see the MSK physio or the advanced nurse practitioner, when it is right, for example, to go to minor injuries. For some people, my experience with constituents is that there is, personally, when should you go to minor injuries and when should you go to A and E and how people can understand what is the best route for them and when to then make access to particular emergency departments. There is a need for us to provide on-going dialogue and explanation to people about an information about what is the best route into accessing the type of support and assistance that you may require at a particular time. One of the things that we have introduced more so in recent times has been through NHS 24 in trying to manage some of the challenge that we are experiencing, particularly in emergency departments, the ability to contact NHS 24 to actually speak to a clinician or advanced nurse practitioner who is able to actually prescribe medication to that discussion with you and then to facilitate the prescription for you as well to reduce the need for you one to either go and see your GP or two to go to the emergency department. Are all the types of initiatives that we want people to understand and be aware that they are available to them and it might be the best route for them to use. I do not think that it is doing one thing or the other. I think that there is a need for us to continue an on-going discussion and explanation to people about the options that are available to them and what might be the best option for them should they require to access healthcare services, whether it be digital, whether it be primary or secondary care. I do not think that we will ever reach a point where everyone will know that is the route I should go. I think that it will always be an on-going discussion and an on-going explanation that we will have to provide to try to help to support people in making the right choices around that. I do not think that we have probably cracked it as well enough as we need to and there are probably more we can do to try to help people to understand how the access of services is. I think that part of the future redesign of services is about engaging the public in that process as well about what the health service will look like in the future and how you might want to access health services. For example, I expect in the future to be able to do much more digitally, but I know that for some people, older people, that might not be the route for them. It might not be a useful tool for them, so there will always be this natural transition of people who will make more use of things like digital and others who will not. We need to make sure that we give people with information the options that are available to them that best meet their needs as well as when they are necessary. It is healthcare so wide-ranging and there are loads that I am sure we could cover today. Community pharmacy is absolutely valuable and pharmacy first is amazing. The feedback that I have had from community pharmacies is that sometimes they feel undervalued in their work. I am interested to know whether there is data gathered about pathways for referral to pharmacy first and whether some of them are appropriate. Community pharmacies could be great at checking inhaler techniques for the right inhaler for COPD and asthma to keep folk out of hospital, so it is about the right inhaler technique for the right person. Community pharmacies should be absolutely valued in their role, but do we track whether appropriate referrals are made? I do not know, but I am happy to check whether we have that data. I can come back to the committee with that. On your wider point, I think that there is a level of lack of public understanding in what you can get from a community pharmacy and some of the treatments that you can get from a community pharmacy. It is understandable that you have an eye infection. I am going to make an appointment to go and see my GP. If you get a mild eye infection, go and see your pharmacist. Your pharmacist will be able to prescribe a medication that can treat it appropriately. You mentioned the issue of inhalers for folk of COPD and asthma or other erwaith diseases. I think that there is still a lack of understanding and recognition around what community pharmacies can provide. That is why I need the first of us on going education of people around what is available through things such as pharmacy, because they are a key part of our primary care services. To get people to make use of them, I am thinking about just going through the normal traditional route of, I will go straight, make a GP appointment when you can be seen quicker and probably much more closer to home if you are able to make use of the community pharmacy for what you have. Community pharmacies sometimes are challenged in dispensing prescriptions because a pharmacist has to be on site. Now we have vending machines, which work because of the way that the regulations deal with part of the pharmacy to allow the vending machine to be used for dispensing medicines. The regulations are reserved to Westminster, which would allow a medication to be dispensed if it was a repeat medication, for instance, that has already been assessed for that patient. Is there any work being done to look at how we can support pharmacists in that way so that work can continue in a community pharmacy to dispense medicines, for instance? I am not sure. I would have to check for you if there is some work that we are doing around that. I am happy to come back to you once I have checked if there is some work that we are doing around that. Cabinet Secretary, you talked earlier about the importance of clinical centres for attracting and developing the skills of specialists, which is very important. You have also highlighted that service redesign is very important and so is enhanced national and regional working. There is a concern that redesign is a euphemism for drive to centralisation. There are large populations north-east being an example that are concerned that they are being disadvantaged, that they are having to travel long distances. There are huge issues in the north-east with buses not turning up. Many people have to get long distances from Montrose to Perth or Ninewells, which is a day out very expensive for taxes. In relation to rural health care, the question is, how can you make sure that people in rural areas are not disadvantaged by any redesign? When we talk about redesign, I do not think that we have ever been at a point where our NHS has been designed. It is always the dynamic process. There has always been an element of redesign taking place within our NHS. I will give you a practical example. In my constituency, we had Falkirkham district royal infirmary and Stirling royal infirmary. They both had orthopedic units, but it became increasingly apparent that, from a clinical perspective, the clinicians were saying that two separate orthopedic departments were not sustainable because they did not have the throughput of patients to achieve the teaching hospital status that was necessary to attract junior doctors in, to register as an etc., and to get the throughput in the department that made it viable. We have moved from having two district royal infirmaries in the fourth valley area to one, which is now fourth valley royal hospital, one single site providing that function. Sometimes these redesigns are not driven by Government wanting to centralise things for the sake of doing it. Some of it is a result of clinical change and clinical demand, and the reality that we are operating in a global market to attract these clinical skills means that some services do need to take place in our major centres because it is just not sustainable outwith those settings in itself. I do not want to see any reduction in healthcare services for your constituents in rural areas, but I equally also need to think about how do we balance out making sure that we are able to meet their clinical needs where it is not possible to get the clinicians to work in that area for the reasons that I have just given an example of my own constituency, which is a practical example. That has happened across the country in different areas where services have had to become located in one single setting. We have sought to try and use in the past, for example, in Aberdeen managed clinical networks for services such as neurosurgery, which was to help to provide support in grampain to continue to deliver neurosurgical services, which was, through support, largely being provided by Glasgow and to some degree by Edinburgh, where clinical expertise, support, etc. can be provided in some of our big urban centres or ideas to some of our other locations in the country. We have tried to use that type of design to try to help to support it. We have tried to use managed clinical networks in some of our highland areas for the delivery of certain healthcare services as well to try to help to support clinical services, including on our island communities as well, to try and help to make them sustainable. We will continue to have to be innovative in the approach that we can take to try to help to support and retain services in our rural areas as best we can, but also acknowledging that there are challenges just because of that. As I mentioned earlier on, every increasing specialisation is taking place within medicine and moving away from the generalist approach that we may have had 30 or 40 years ago, which has resulted in specialist centres becoming more and more of how clinical services have been designed and delivered as well. I accept your challenge and I recognise and acknowledge the concern that you are raising. I certainly, as a health secretary, would not go into anything thinking about redesigning services that are just for the sake of doing it if it was against clinical advice, but I equally have got to recognise that if there are occasions when boards have to make decisions on the basis of clinical advice for safe services for patients, we have to take that into account. I do not think that we will be at the point where we will get the final design. I think that it will always be a dynamic process, but I think that we have always got to be innovative here in Scotland because of the large rural areas that we have got to look at how we can try to help to support rural services where we can to reduce the need for patients to travel, to deliver services as close to people as possible alongside that, to increase specialisation, to deliver safe services and to try to get that balance right as possible. I acknowledge that we might not always get the balance right and we should not be frightened to admit that. Sometimes we should revisit those things if necessary, but it is a competing balance and it is a challenge that we will have to try and manage as we go forward in areas like your own. I have a short follow-up for my cabinet secretary. I understand the need for this very delicate balance, but do you accept that there are two major issues here that people are having to travel with this new redesign and this drive for centres of excellence that people are having to travel long distances in? It is not just the time where there are several examples where they are very poorly. For our green colleagues, there is an additional carbon footprint of people having to, if they are lucky enough to have a car, they can go in the car, but it is a day there and back for treatment. The extra bus travel is not just the pain and upset for patients but the additional carbon footprint. If you look at, for example, some of the capital investment that we have made recently around national treatment centres such as Burn in the Highlands, the Bairden anchor in Aberdeen that we are providing as well, the new hospital in Orkney as well. It is not a pre-conceived view that we want to see more things centralised. That is not the approach that we are taking. Where we can make the investment in our rural areas is doing that to deliver those services in rural settings and to provide the right infrastructure in rural settings. What I am just acknowledging is that there is a trend in the clinical setting that is not a Scottish trend, it is not a UK trend, it is an international trend. We have to acknowledge that and recognise that. However, that is why, as John Burns rightly said, in response to a question earlier on, some of our most innovative health boards are rural health boards because they have to think about how they can deliver services in a different way in a rural setting. We will continue to do what we can to help to support them achieving that. I mentioned, for example, things like the Bairden anchor and the new NTC in Highland. Those are all examples of our determination to try to make sure that we are delivering as much as we can in some of our more rural areas in Scotland. However, we also have to acknowledge that we need to deliver services in a clinically safe way. There will be occasions when it is not possible for us to deliver all the services that we would want to in some of our rural areas that it will require people to travel into urban areas. You will recognise that that is not a new thing in itself. That has always been the case for some people in rural areas, but there has been an increasing tendency with some of the specialisations that have taken place. The final point is that we want to see more people being treated at home, which is why we are expanding our hospital home programme, so that more people will get to clinical care in their own bedroom, in their own home, never mind in their local hospital. We have more than doubled that, increased funding again by nearly £4 million to see further expanded. That has a particular benefit to patients in rural areas in itself. We just need to continue to recognise that it is a dynamic situation and we need to continue to adapt to it. We have to be innovative in Scotland, given the particular challenges that we have around our rural communities. I will do with an icon to try to help to support that and support our rural health boards in being able to deliver as best a service that they can with the near local area. I will move on to our next theme on staffing. We have a lot of interesting questions here, so if I could ask members to keep their questions concise and if I could ask the panel and the Cabinet Secretary if you could do likewise, please. I will move to Gillian again. Thanks, convener, and good morning to the panel. Touching on some of the issues earlier that Emma Harper brought up around apprenticeship schemes, we heard from Professor Archibald from NHS Tayside, who described the challenges that she has faced with respect to the recruitment of healthcare professionals who are not nurses and doctors and the effect that this has on NHS Tayside such as estates, departments, staff and allied health professionals. What more can Government do to promote those perhaps less well-known roles, but the vital roles that they are and the various pathways into them, like modern apprenticeships? I think that you touched on part of the thing that we can do to try to help to make those areas attractive. We will obviously, NHS Scotland will recruit, as it is an apprenticeship programme, which recruits individuals into a whole range of areas that are non-regulated professions, so they will be into estates, departments etc. One, we can do that. Two, is to make sure that they have good terms and conditions. Three, in the regulated professions area, is about trying to provide alternative pathways into it. So, you know, earn as you learn programmes, looking at providing apprenticeships into programmes that presently just now are all very much dependent on university degree-based programmes as well, allowing folk the ability to be able to flex into other professional groupings. So it might be, in terms of the skill sets that they have got, is that they, for example, around advanced nurse practitioners, some of the prescribing work that they can do as well, all of these measures all play a part in helping to meet some of these challenges. So, you know, terms and conditions, training opportunities, routes into training as well for AHPs and others, all play an important part. I know, for example, the really good discussion with Royal College of Pediatrics recently, who were talking about the importance that apprenticeship programmes could actually have for individuals who may already have a career, but they actually want to move into pediatrics and have been able to flex into that and earn as they learn type programmes, all of which could actually have a significant impact. And I know part of a pilot project that they ran in with Greater Glasgow and Clyde was really, really successful in being able to deliver that. We want to agree to take it away and look to see how we can do more of that. So I think that's the sort of thing that we need to do much more of to try and get more folk into some of the regulated professions, but also the non-regulated areas as well. That's great. Thank you. We've heard from a number of boards about the impact of stress and anxiety on staff wellbeing, particularly on sickness absence. We've heard this from evidence over the past few weeks that boards are taking action to improve wellbeing, for example, by putting in place peer support networks and speaking up ambassadors. But what support can the Government provide to ensure that such schemes are being rolled out nationally, where good practice is taking place, it's being identified and replicated across the health service so that everyone's receiving the same support? Is there a minimum standard of wellbeing support that boards are expected to have in place and how is that monitored? In terms of minimum standard, I'm not sure, but I'm happy to check that for you and come back to the committee on it. In terms of the issue around wellbeing of staff, I think that the NHS isn't anything without its staff. Staff are absolutely critical to it, so supporting their wellbeing is obviously of high importance. I would want to—if there's one thing that frustrates me—if it's frustrated me when I was health minister previously and it's frustrated me since I've come back into health—it is the inability to do things once for Scotland. One health board is doing really well and trying to get other health boards to adopt it can be a real challenge. There is a piece of work that we're doing around this once-for-scotland approach, which is trying to make sure that, where we see good practice around supporting staff and wellbeing is how that can be utilised in other health boards when we're sharing that experience and that knowledge. There's work that we're doing around how we can try to help to support that happening much more effectively as well. Learning from other boards' experiences is important and sharing that experience. Obviously, there's a national wellbeing hub that we provide, which provides 24-7 support for staff. There's a range of different programmes through that, which are available to staff, which is what we help to provide at a national level. The key thing is that, where there are good initiatives, we're trying to make sure that other boards learn from those initiatives and that we utilise those experiences much more effectively. That's great. Thanks, convener. I'll move to David Torrance. Thank you, convener. Good morning. Around vacancies in NHS Scotland, I think that medical and dental consultants are sitting at about 7 per cent vacancy. I know that, in my areas, it's a real difficulty of trying to get a NHS dentist. How are we going to encourage shortages in specialised positions like that in the NHS? How are we going to recruit to fill them in? A combination of different factors. When it goes back to the point that we made earlier on about NHS Scotland being an attractive place for them to locate and to be based before I bring Stephen in, who can maybe say a bit more around some of the workforce aspects of that. We undertake a considerable amount of work through NHS Scotland to nes in order to try to make sure that NHS Scotland is an attractive location that we provide on-going training and support for our clinical staff through education programmes to support them. It's worth keeping in mind that we are fishing in a global pool for those skillsets. If you look at, for example, the challenges that we have around oncologist, ophthalmologist—all of those are endocrinologist—there is a global shortage of those skillsets. We need to do everything that we can to try to help to support and retain people who are within NHS Scotland where we can where we have those skills. Medical recruitment into NHS Scotland. For example, we have, in terms of attracting junior doctors in 2022, we managed to fill about 93-94 per cent of all the posts, which is the highest since records began in recruiting junior doctors into NHS Scotland. We are increasing medical places in the last couple of years. Medical places have increased by over 50 per cent. That's at 55 places. By 67 per cent on 2016 intake numbers and around 500 places since 2016? Increasing training opportunities as well is part of how we manage some of these challenges. I don't know if, Stephen, do you want to say a bit more about the workforce and some of the work that we're taking forward to try to help to recruit people? We broadly brigade all of our work, whether it's for medical or non-medical recruitment under the auspices of the workforce strategy that takes the same theoretical framework approach—plan, attract, train, employ, nurture—partly because you need to look at both ends of the spectrum at the same time. As the cabinet secretary has already explained, in terms of looking at medical growth and fill rates, we've already done quite a lot around expansion at undergrad and into foundation. You'll see that continue as we move more of those expanded undergrad places into the pipeline. Similarly, the other key aspect to this is retaining the workforce that we've already got, either through approaches to retire and return, flying finish, and other initiatives that allow people to take a slightly longer and more stratified approach to their career. We convened a group earlier in the year looking at consultant retention in areas of shortage and specialist need, and that's broadly recommending three sets of things to health boards, one of which has been dealt with in terms of pension support, but also around adjusting working patterns and job patterns towards the end of the career, and also encouraging consultants to make career choices before they get to 60 to allow them to stay in the workplace for a longer period of time. There's a set of things going on at both ends of the spectrum that hopefully allow people to stay in post for longer but adapt that to the changing needs across the career. My colleague Emma Harper touched on the earlier cabinet secretary and evidence to the committee in rural areas. Even if there is jobs there that can fill, housing is a real problem. Have you ever thought about working with partnerships with local authority to build specific housing, affordable housing for NHS staff or giving money to NHS boards to build their own accommodation? I don't think that we've given money to health boards to build their own accommodation. I'm sure that we have had some partnership work in the past between health boards and local housing providers around what they can do to try to help to support them in making affordable housing available to them. Again, it's out with my portfolio. I'd be more than happy to check with my housing colleagues around what specific work they're doing with boards around trying to address the issues of affordable housing. Of course, there was a time in the past when we actually had accommodation for staff in NHS, which has obviously changed many years ago. I'm more than happy to take away and check with our housing colleagues on any specific projects or programmes that they've taken forward. There have been some programmes developed in some rural settings that are about bringing together public sector investment, which is health investment, housing investment and wider community investment, to try to utilise that money in a way that helps to deliver more infrastructure in an area. However, I'm not sure whether there have been specific programmes to provide housing for staff that are working in NHS. I think that it will be a more general programme, but I'll check. Just very quickly, following on from Gillian Mackay's, you might want to comment on the safe staffing legislation and the commitment to have that in place by April 24 on how you feel that's going. However, my particular question is really just to highlight key points made by board chief executives in terms of staffing. Geoff Ease from NHS Dumfries and Galloway said that, technically, I cannot afford one in 10 of my workforce, but I clearly need all these people and more to meet the demands of the service. Ralph Roberts from NHS Borders, there's no doubt that what I'm hearing most from staff is their frustration about not being able to do the job that they came in to do. Claire Burden in NHS Ayrshire and Arnann said that there's a lot of anxiety and stress, a key driver of staff absence because of the current climate and it's being so tough. Cabinet secretary, if you feel that it is fair to say that the previous Cabinet secretary didn't get this right in terms of staffing, staff terms, conditions, recruitment and their place in the workplace and whether you have a plan to take that forward and you think that you can turn around that sort of staff recruitment and retention. You seem to have a particular focus on my predecessor. Not at all. It's just that he was part of the on-going input into the NHS so far. I just know that you seem to have a particular focus on him. Let me try and deal with some of the issues. It's just of interest to see whether you are going to change direction in terms of making some of these things happen. Let's try and deal with some of the facts around these issues. In terms of staffing limits, we've got work being taken forward just now through workforce planning. It's engaging our trade unions and so on. Stakeholders and health boards are in planning for that. Right now, we are presently on track to take it forward into next year and love it within next year. That works on going to present moments. It's a complex piece of work but the working groups around some of that are already progressing. In terms of the financial pressures and the stressed anxiety that staff are experiencing, I wholly and fully recognise that. A big part of that has been because we've come through a pandemic, which has placed huge pressure on our NHS in a way that it has never experienced in 75 years of its existence. We all need to recognise that and acknowledge that. If you focus on my predecessor is your intention and if you want to look for examples of taking very direct and clear action to help to support and reward staff, I can't think of anything more than what was the significant improvement that we made in paying conditions to agenda for change and the 14.5 per cent that was provided to staff, the largest uplift for healthcare staff in the UK. More so than was provided by the health secretary in England, which I think demonstrates his determination to provide financial reward and support to staff within NHS Scotland, recognising the enormous contribution that he made during the course of the pandemic. That's a very practical example of my predecessor taking clear action and showing clear leadership in delivering such a significant improvement in paying conditions. It doesn't stop there because agenda for change has also been reformed as a part of this, which again was a direct request that came from the trade union groups. That work is now already started. The working groups that are responsible for taking that forward has already started. Areas such as I mentioned, the nursing midwifery task force is already up and running due to its second meeting, which I chair. The working groups that are looking at the reform of different parts of agenda for change has also been taken forward. You mentioned terms and conditions as an example of demonstrating your commitment to supporting staff. I think that my predecessor in what was agreed and provided through agenda for change demonstrates that in a way that wasn't provided in other parts of the UK, where other health secretaries took a different route and provided less. In my view, that is a very clear signal of where our priorities are and why we value staff. I am not going to sit here and try to pretend that our NHS does not face significant challenges just now. It is now recovering from the pandemic, the legacy of the pandemic. We are going through a period of austerity in the whole of the UK at the present moment. It is having a significant impact on public finances. We are dealing with record levels of inflation or have been dealing with record levels of inflation. We have a cost of living crisis that households are having to manage as well. That impacts on staff and their health and wellbeing. We are dealing with significant increases in fuel costs that have an impact on public finances. Construction costs, maintenance costs are all up significantly. All of those are having an impact on our NHS. You can be absolutely assured of what I will do. I will continue with the approach that was taken by my predecessor in valuing and recognising the staff and the importance that they play within our NHS and making sure that we maximise the level of investment that we can put into NHS Scotland, demonstrated by the fact that we have put in £730 million this year, a further £200 million on top of that, as I mentioned earlier on. We are ahead of trajectory or trajectory on the 20 per cent increase in this parliamentary term, again during clear leadership and putting finances into the health service where we can. All of those factors will play their part, but equally doing what we can to help to support our staff and to recognise the important value, the critical role that they have within NHS Scotland. I think that the point I was just talking about is that we need to move on. There are other people who have questions and we still have three more themes to get through. Very briefly, Emma Harper, and then we do need to move on. I will be very brief. Scott Jem is unique to Scotland and I will be interested in hearing feedback about that. Also, the Rural GP Association of Scotland has concerns around recruitment, retention and workload. How is the Government working with the Rural GP Association of Scotland? There are a number of programmes that we have to support the Rural GP initiative, so some of it is about financial support, making an attractive setting for them to work within. Stephen can say a wee bit more about that and he can also say a wee bit more about Scott Jem as well, which is a specific, as you mentioned, Scottish-based project to help to support recruitment. Very briefly, broadly, Scott Jem is functioning very well. We will look to get a second cohort of graduates. It has expanded from 40 to 55 places. It is all graduate entry. It is all focused on remote and rural and with a particular interest in primary care practice, with a lot of the clinical type, clinical placement activity taking place in Highland. We will consider again as part of this year's intake in October whether the scope for further expanding the number of places as part of that annual review of expansion of undergraduate medical places. In terms of specific support for remote and rural GP practice, we continue to fund bursaries for GP ST training. Last year it was 98 bursaries and it is around 100 for this intake. Broadly, we have a very good uptake rate on all of those. We also have specific financial incentives for supporting rural practices, recruitment and retention premiums as well, looking at SIMD index multiple deprivation and the remote and rural situation of individual and rural GP practices. We are going to move on to our next theme. Can we please have concise questions and concise answers? Stephanie Callaghan. Thank you, convener, and good morning panel. You have already touched Cabinet Secretary in how health inequality is slow from the socio-economic inequalities. That pressure puts in NHS services. You are welcome to say a wee bit more if you wish. I am interested in what work can be done to tackle inequality and reduce poverty, with a clear focus on preventing ill health and reducing pressure on services. Are NHS often in dealing with health inequalities? The illnesses that are driven by health inequalities are the result of social inequality. Our health service is often in dealing with the symptoms of social inequality that manifest themselves in health inequalities. It is important that we take forward programmes such as reducing child poverty, the programmes that we have got, for example, around the Scottish child payment. All of those will have an immediate benefit to those individuals, but they will have a long-term benefit in helping to reduce child poverty, which we know can result in health inequalities. Factors like that, the work that we do around tackling tobacco use, with reductions that we want to continue to build on, is going forward. We have alcohol misuse. A recent report was published today by Public Health Scotland, again showing that minimum unit pricing has helped to reduce alcohol-related deaths by over 13 per cent. All those factors play an important role in helping to support us in preventing ill health. Alongside the social policy actions that we take to tackle social inequality will all be critical to supporting us in the preventive agenda within health. I am interested in how I focus on tackling inequalities in a shift to primary and secondary preventative care that can help to ensure the financial sustainability of the NHS long-term. I mentioned earlier that the burden of disease over the course of the next 20 years is projected to increase by some 20 plus per cent. If we are to address that, we need to have a clear focus on prevention to try to reduce some of that burden of disease, particularly as our population gets older and people are living longer as well. The measures that we take around prevention, the public health measures, the immunisation programmes, the screening programmes that we have all play a critical role in that. That requires action both at a primary and secondary care level. There is no doubt in my mind that we will have to make sure that we are doing as much as we can around the prevention agenda if we are to try to help to manage what is going to be a very significant increase in the disease burden that we will experience over the course of the next 20 years. You have mentioned clearly that prevention is critical to controlling overall cost pressures on the NHS, yet the NHS in Scotland has the lowest share of preventive spend of any OECD healthcare system. One of the ways to address this is through the mental health challenges that this country faces. The Government had committed to mental health and wellbeing service for every GP practice and 1,000-year-olds to support community mental health resilience in the 2021-22 programme for government. Despite health and social care partnerships planning for the roll-out of those services and the vital role that community-based support provides for prevention of mental health crises reaching an acute situation, implementation has not yet started. Can you please explain why that has not happened and why that has not been a bigger priority given it was in the programme for government? Investing in mental health is obviously a priority for the Government. We have saw significant investment over the course of the last decade or so. In terms of the specific workers that you mentioned, it is a financial aspect. The biggest challenge here is trying to manage all the competing demands that we have within the NHS budget. It is a financial constraint upon us that is limiting our ability to be able to run forward with the programme as it stands at the present time. Where financing becomes available to us, we will be able to do so. You will be aware of other projects and support that we provide around the link workers that are very valuable within GP practices that can help to signpost people to other services, including those who have mental health conditions. However, the principal purpose that we have not been able to take forward this programme is just a lack of finance being available to us to extend it in a way in which we would have wanted to. I recognise your point that finance is tight. You have a relatively privileged position, I suppose, on being the biggest expenditure area in the Scottish Government and have had a 6 per cent cash and 3 per cent real terms increase in the projected budget for the next financial year. We know that, where we do not aggressively pursue opportunities for savings and prevention, it ends up incurring costs somewhere else in the system. In one area, we have identified in our discussions with chief executives as NHS 24 where we have seen a 580 per cent increase in calls to NHS 24 based on an annual rate of calls associated with mental health problems. In dental health calls, we have also seen a significant increase with 67,000 calls made in 2022-23 compared to just under 30,000 in 2020. Clearly, those pressures have been visited elsewhere in the system, which seems unsustainable based on those figures. Certainly, they were shocking to us when we heard them. The cabinet secretary recognised that there needs to be more investigation of where we can aggressively pursue opportunities for savings and push that spend into prevention because it is otherwise going to incur a cost elsewhere. Our individual health boards have a recurring 3 per cent saving target that they have to meet in order to try to look at freeing up resources to invest in other parts of the health service provision. It is money that they retain, I should add, but it is to try to free up money to make sure that they are using it as efficiently as possible. There are many things that we can do with additional finances and financial support. I recognise that I hold the biggest part of the public sector's budget, but, as we have already heard, there are boards that are facing extreme pressures at the present time across a whole range of services. If I choose to put extra funding into the provision of mental health workers within GP practices, it involves taking money away from somewhere else. It is not a spare pot of cash to drop on. It is money having to be taken away from another service. Very few people have ever come to me and said that they should cut money from that service and put it into that service instead. That is more valuable, because they are all valuable and important. What we will have to do, and as we have committed to increasing the health service budget by 20 per cent in this parliamentary session, is to continue to try to make as much use as we can of the investment that we have available to us that maximises the benefit that we have. I hope that, as we go forward, some of the additional costs that we are facing at the present time, if inflation comes down, it looks like it is not going to come down slowly as we would want it to, if it comes down, if energy costs come down, is that we will see some of that financial strain ease over the course of the next couple of years, which will allow us to then look at how we can flex some of that resource into other areas, into front-line services in a way that we have not been able to do at the present. I would hope that we will be in a position to do that, but we are also going through a period of public sector austerity, which is having an impact on our budgets. Your 20 per cent increase. One of the other commitments was for mental health share of health spend to rise to 10 per cent, currently around 8.8 per cent, and we have effectively had a restoration of the cut due to the emergency budget review, so we are stuck at the moment on 8.8 per cent. What is the push ahead to that 10 per cent argument that we are going to get there? What is your view on how achievable that is? Our intention is to get there, but it is going to be challenging in the present financial environment. As we move forward in this parliamentary session, we will do what we can to try to get to that 10 per cent target. Right now, I do not have the clarity in what budgets will look like next year or the year after that, so there is an element where there is a level of uncertainty about what future budgets will look like, but it is certainly the target that we are aiming to deliver within this parliamentary session, and it will not be through a lack of desire to try to achieve it and to make sure that that investment happens in this parliamentary session. Cabinet Secretary, I know that this is unusual, but could I ask Richard Diary to be able to accommodate an extra 10 minutes for the committee? Of course, yes. In that way, I think, we will manage to get through all our questions. Providing, we are still concise in questions and answers. We are going to move to the next theme, to a test fight. Cabinet Secretary, you mentioned the Baird Family Hospital and the Anker Centre, so I am glad that it is at the top of mind for you. Thank you for that. There have been alarming concerns about the delays with the water system and ventilation system, which you are aware of. Just to hear from you your thoughts on how we can make sure that lessons have been learned from ventilation and water systems in other hospitals and what you can do to oversee this to prevent any issues with these two centres moving forward. I recognise the concern, and I acknowledge the concern that people have around some of the delays that have been caused as a result of issues around the water supply and ventilation system within it. If anything, picking those issues up demonstrates the lessons that have been learned. That is that NHS Assure has to sign off and approve a capital facility of this nature before it can be declared fit for use and have identified deficiencies and have addressed those with the board. There are maybe some lessons for the board in managing a capital project of this nature and how it could have possibly avoided that. However, the check system that we have in place has caught it and has identified it, and the appropriate measures will have to be taken. If anything, it is a demonstration of the lessons that we have learned from previous experiences, where facilities were about to open and then problems were identified at an earlier stage in order to be addressed. Of course, that results in some delay, but it would be better for that to have not happened in the first place. However, I would expect us to look to see what we can learn from NHS Grampian's experience in taking forward this project. However, I am reassured that the NHS Assure process has captured and identified the problem to prevent it from being embedded even further at a later stage in the project. I want to pick up on some of the issues that we heard from chief executives around maintenance backlogs. NHS Grit and Glasgow Clyde cited backlogs at Inverclyde Royal and Royal Alexander hospital of £100 million and £80 million respectively. Most boards will allocate their resource based on what outstanding repairs pose the highest risk to patient safety. However, is it sustainable for boards to take that more reactive approach to addressing issues only once to become a serious issue to patient safety, as opposed to having a much more robust preventative maintenance programme? What does best practice look like and how can we help health boards get on to a more preventative approach for our reacting to issues that could potentially cause deaths? Ideal would be in a position where we would be able to try to address as much of the backlog as possible to try to reduce the risk of it becoming a patient safety issue or a safety issue for the staff within building challenges. Capital budgets do not provide for that in itself to allow us to be able to achieve that. Boards work in a very dynamic environment in which they will address maintenance backlogs on the basis of priority. Some of it will be for clinical safety purposes and then they will continue to work on that basis. We have to, alongside the need to provide new facilities and also deal with the maintenance aspect, there is a huge pressure on our capital budgets. I would expect boards to work on a dynamic basis to identify what are the critical elements that have to be taken forward to make sure that they are being addressed efficiently and effectively so that they do not interrupt clinical services or issues around safety. It will continue to try to invest in our estate as we go forward for both maintenance and also for new facilities where necessary. There was a particularly shocking example that was cited by the NHS Greater Glasgow and Clyde chief executive about the Institute of Neurological Sciences, where the backlog in maintenance had come at a human cost with 17 incidents of patient death or harm in the past five years and the board spending £3 million on private surgery for patients. Clearly, there is an obvious business case there, potentially, to accelerate our expedite investment in that particular infrastructure where there is already a cost associated with it both in terms of patient death but also costs and private provision to make up the difference. Even structural issues around, for example, the NHS Lothian, citing the Edinburgh Infirmaries Accident in the Emergency Department, was designed for a population of about 85,000, but it is actually seeing around 120,000 to 130,000 people coming through it. It is structurally just struggling to cope with the physical infrastructure. Do you have a risk register at a national level that you are personally overseeing to demonstrate where we really need to prioritise capital investments based on those metrics around patient safety and clear structural challenges? Is that something that is reported into you and you can take personal action on it? No, it is led on by boards, so director themselves who are close to it. For example, you mentioned the Neurological Institute in Cunosibeth. If there was a business case for investment to be made in additional capital investment into the facility, the health board would be responsible for drawing that together, putting that business case that would actually come into our capital. There is a capital allocations team that looks at those issues and all the various demands that come in from different boards around that. However, the lead in those matters is within local boards who would know what their estate needs and what the challenges are that they have actually then got. That then comes into the national health infrastructure board who would consider their proposals. There is a mechanism there for boards to utilise as and when. Your second point on the challenges that you have in Rowan Ffirmory is a reflection of what that is a hospital that is 20 plus years old now, just over 20 years old now. There is a significant demographic shift taking place in the country, so we are seeing a population shift going from the west to the east, which is creating additional pressures on public services within the east of the country in itself, which has happened over the course of the last 10 to 15 years, putting pressure on the front line or the front end of hospitals like Edinburgh and Ffirmory. Again, they have the opportunity to look at what they would then put together as a business case for investment, expanding that particular facility and that would be for the board to lead on that and then to submit that as a proposal to then be considered alongside all of the other health capital expenditure proposals. Do you feel the boards are moving quick enough on those proposals to get cost avoidance? If we are going to expend in these capital programmes, what will avoid revenue expenditure? Are you pressing them on the need to bring those forward quicker? Yes, but we also have to keep in mind that capital investment right now is a very expensive exercise to undertake because of the very huge capital inflation that we are facing at the present moment. Construction inflation is running away ahead of standard inflation, so we are up in double digits. That has had a significant impact. Our capital budget has been cut, so by around 5 per cent I think it was, by the UK Government. That has a direct impact on us. Also, the value of what we have buys us less because of construction inflation. We have to be very nimb on our feet and we have to be very focused on exactly how we can maximise the investment that we are able to make to deliver on the right capital investment project. In my view, boards are not slow to flag up to you where they need capital investment and what that capital investment would look like. I certainly would never discourage a board from bringing forward a proposal, but equally our boards will understand the financial pressures that we are under and it may not happen in a timeline that they would ideally want it to. Thank you, convener. I am glad that you mentioned NHS Lothian because there are some real issues with the acute mental health where patients were lying on mattresses on the floor because a unit designed for 105 patients was coping with 129 patients and there are no low secure mental health facilities available in Lothian. There is going to be this big expansion with a number of people that are coming to Lothian. A proper rehab facility and an essential low secure unit will cost somewhere between £33 million and £61 million, but currently the cost of doing nothing is around £360,000. This also creates an issue for patients because they are being scattered around the country. Would the Government be looking to help secure investments into capital projects such as this, which is much needed in Lothian? Where is the business case put forward for a capital investment project by a health board? It will come in and it will be considered through the normal process that we have in Government for considering proposals, but it has to be set alongside all of the other competing demands that we have in the capital budget, which has been cut. We would have to balance that against other competing priorities in NHS Scotland from different proposals, from different boards. If the board brings forward a proposal, it will go through the normal process, but it will have to also be considered alongside all of the other capital projects in NHS Scotland. That concludes our themes, but there are a couple of brief supplementary questions on other issues. Cabinet Secretary, I believe that Sandish Galhany has one of those. Thank you. I brought this up before, Cabinet Secretary, not with yourself, but I brought this up with boards and I brought it up with the previous Cabinet Secretary. Greater Glasgow and Clyde and other health boards, but Greater Glasgow and Clyde in particular, has information leaflets in many different languages, but Hindi is not one of the languages where these information leaflets are in. Why is that, despite me bringing this up on a number of occasions? Will you look to urgently change that? I do not know why that is the case. I am more than happy to take it away and have a look at the matter to respond to you directly on the issue. It seems a reasonable issue to be raised as needed to be addressed, but I do not know the background to it, I do not know the reason for it, but I am more than happy to take it away and have a look at it and to come back to you on the issue. Last week, the committee took evidence from the Scottish Ambulance Services Chief Executive where I had asked now to declare my interest as a registered mental health nurse. I asked about the impact of mental health assessment units and the redesign of mental health on scheduled care, what impact that had on Scottish Ambulance Services. They have written back to the committee today saying that, in May this year, they had seen a reduction in patients conveyed, and I am assuming to A&E, which sat at 50.2 per cent. I am quoting here that the impact of that had reduced the overall service time and at least 34 hours of crew time in total back into the Scottish Ambulance Service in May alone. That is before you look at the impact that that has on patients being able to access appropriate services at the first time of asking or more speedily. How can Scottish Government and NHS Scotland continue to improve access to pathways for urgent and unscheduled mental health care and build on some of those games that have already been made? It is a demonstration of a very innovative approach that has been taken by the Scottish Ambulance Service and the way in which it is providing services. It is not just that, but the services that are being provided through NHS 24, where I know that they have made a significant amount of resource available to help to support individuals who are presenting with mental health issues. There has been a significant improvement in their performance in that area. The chair of the board yesterday was highlighting this issue to me about how mental health supports a key priority for them going forward as well. What we are seeing is, particularly with the Ambulance Service, that it is becoming more of an outreach service in some ways. It is probably not the best way to explain it, but it is becoming much more that see-and-treat approach that is taking place, much more where it is able to provide direct interventions to patients there and then, rather than having to convey them to an accident emergency department or to a mental health unit instead. That is an area that we want to continue to see innovation development going forward. You will be aware of the additional finance that we are providing to the Scottish Ambulance Service to increase recruitment. It is an expanding area, but some of the preventive work and support that it can provide around urgent and unscheduled care is really important. It will be proved to be increasingly critical going forward to help to sustain and support our services. I absolutely want to continue to build on that and to progress on that both in a mental health and non-mental health setting. I thank the cabinet secretary for indulging the committee with a little bit extra time. It is very much appreciated and it allows us to get through all of the members' questions. I thank the other members of the panel for their attendance today and for their answers. The next item on our agenda is to decide whether to take items 3 and 4 in private. Are members agreed? Thank you very much. This is the committee's final meeting before summer recess. At our next meeting on 5 September, we will be undertaking scrutiny of winter planning and preparedness in health and social care. That concludes the public part of our meeting today.