 The next item of business is a statement by Jeane Freeman on NHS performance. The cabinet secretary will take questions at the end of her statement, so there should be no interventions or interruptions. I call on Jeane Freeman, cabinet secretary, please. Today, thanks in large part to Scotland's NHS, our people are living longer. That's good for all of us, it's good for our communities, and it is a testament to our health service. It does mean, however, increasing demand on our NHS, and that increased demand comes alongside the need to respond to medical advances, to effectively provide preventative care and to address underlying health inequalities. Those are not challenges that Scotland alone faces. They challenge healthcare systems across the world, but it makes it essential that we ensure that our whole system has the capacity, co-ordination and workforce to deliver the best care possible in every setting. We do so in an uncertain environment, not least the damage that Brexit will do to our health and care services. That improvement plan, which I am publishing today, focuses on reducing the length of time that people are waiting for key areas of healthcare. Simply put, some people are waiting too long to receive the care that they need. As with the recent financial framework, that plan's investment is predicated on the assumption that the consequentials that the UK Government has promised will be delivered as a true net benefit to the Scottish budget. On that basis, the plan commits total investment of £535 million in resources and a further £121 million in capital over the next two and a half years to make a sustainable and significant step change in waiting times. That is in addition to the £200 million already being invested in our elective and diagnostic treatment centre programme. This increased investment will support reforms to increase capacity where it is needed, reduce the numbers of people experiencing long waits, reshape delivery to ensure sustainable performance against targets in the future and achieve the necessary balance of care to support that. Over the next 30 months, we will deliver phased and decisive action with clear milestones to secure substantial and sustainable improvements to performance and significantly improve the experience of patients waiting to be seen or treated. By October 2019, 80 per cent of outpatients will wait less than 12 weeks, 75 per cent of inpatients and day cases eligible under the treatment time guarantee will wait less than 12 weeks to be treated and 95 per cent of cancer patients will continue to be treated within the 31 day standard. By October 2020, 85 per cent of outpatients, inpatients and day cases will wait less than 12 weeks. By spring 2021, 95 per cent of outpatients and 100 per cent of inpatients and day cases will wait less than 12 weeks and 95 per cent of patients awaiting cancer treatment will be seen within the 62 day standard. In meeting those commitments, we will ensure that clinically urgent patients and those waiting longest are prioritised. Our focus is on both physical and mental health, so following our programme for government's £250 million package for mental health, the Minister for Mental Health will come back to this Parliament later this year to set out the specific actions and targets to improve mental health performance. Achieving all of this requires work to address existing targets, but it also requires a whole system approach, spanning hospital, primary, community and social care, to really increase sustainable delivery. Solutions will differ across the country and across specialities, but the drive for improvement will be national in scope. It will require national action to increase capacity. That will build on our programme of investment in our new elective centres to provide additional capacity to meet additional demand and protect the scheduling of elective care from the pressures of unschedule care. Through the improvement plan, we will accelerate delivery of the elective centre programme, including the operation of a new CT scanner at the Golden Jubilee, coming on-stream from 2019. The additional capital investment will include £17 million at the 4th valley hospital, which will include putting two new theatres in operation and putting additional MRI capacity at the hospital by the middle of next year. That will be followed by elective centres in Highland, Grampian, Tayside and Lothian, and a second expansion at the Golden Jubilee. We will be looking to bring forward where we can the delivery dates on those important new centres. Working with the Scottish Access Collaborative, we will focus improvements on those clinical priorities where pressures are greatest. Across all specialities, we will improve productivity through a sustained application of state-of-the-art technologies. One example of how we can use technology to improve performance and the patient's experience is that, by this November, we will launch a scale-up challenge to mainstream the attend anywhere video consulting platform. Work is also under way to accelerate how artificial intelligence and automation can reduce waiting times. However, those actions alone will not be enough. We must develop new models of care that support more sustainable services and alleviate the demand on secondary care and reduce the pressures on services that come from increasing unstreadled care. Community and primary care services are playing an increasingly critical role in ensuring that patients can receive more timely care closer to home. Our commitment to changing the landscape of local health and care was reaffirmed in the recent joint statement with COSLA on health and social care integration. Over the next year, we are accelerating the whole system redesign of local patient pathways through integration authorities, NHS boards and clinicians. That will help to shape the front door services of hospitals such as A&E, helping to improve their performance and ensure that everyone gets access to the most appropriate care in the right place. We are implementing the new general medical services contract and supporting the new primary care improvement plans, so local services can be redesigned to allow GPs extra time for appointments, requiring longer discussions and building multidisciplinary teams. At the same time, services will be improved through regional delivery and national boards plans, so services can deliver improvements on a cross-boundary basis. The wider public discussion and engagement on the draft plans will enter a new phase next month. We know that the action requires a supported and skilled workforce. While NHS Scotland's workforce has grown for the past six consecutive years, there remain key staffing constraints. We are making significant investments in staffing. We have already delivered a three-year pay deal for all agenda for change staff, providing consolidated pay increases of at least 9 per cent over three years for all those earning up to £80,000. We are creating 2,600 extra nurse and midwifery training places over this Parliament and investing £3 million to train an additional 500 advanced nurse practitioners. The number of GP training places is increasing to 400 a year, and we are investing more than £23 million to increase the number of medical school places. Over this Parliament, we are training 1,000 paramedics to work in the community, helping to reduce pressure on A and E services. Those are some of the workforce improvements that we are taking, and the improvement plan will build on those. We will invest £4 million over the next three years in domestic and international recruitment for GPs, nursing, midwifery and consultant specialties with the highest existing vacancy rates. We will develop a fresh approach by focusing activity to help to address priority specialty areas with global shortages in areas such as psychiatry and pediatrics. How we plan our workforce is crucial. Our SAFE staffing bill will introduce requirements to ensure the right level of staffing for the workload associated with patient need. We are leading other UK nations by publishing a fully integrated health and social care workforce plan by the end of this year, setting out how we will ensure that we have the right numbers of staff in the right place at the right time to provide person-centred, safe and effective care. In acting to reduce current levels of waiting times in key areas of care, our responsibility is also to increase the sustainability of our health and social care system. The successful future of that system is predicated on targeted investment and sustainable reforms. Patient satisfaction is high, our NHS workforce is at a historically high level and investment in our NHS is at a record level. All of that is a strong foundation for our work and for the carefully phased, targeted action that this plan sets out. Alongside the £850 million of additional investment over the next two and a half years, it is decisive action that will deliver results for patients and for our NHS. I commend this plan to Parliament. Cabinet Secretary, we will now take questions on the issues raised in this statement. I have got about 20 minutes to allow members to ask their questions. I have asked those members who want to ask questions, to press their request-to-speak buttons now. I call on Miles Briggs, who is followed by Monica Lennon. I thank the cabinet secretary for advance sight of her statement and welcome Monica Lennon to her position. Every MSP in this chamber will have constituents who will ask for their help when they are faced with cancelled operations or unacceptable waiting times. Here in Edinburgh, for example, what are my constituents with severe hit problems? I was told in June that he could be waiting until February next year just for an initial appointment with an orthopedic consultant before he would be added to a waiting list. We hope that this action does see progress, but the fact stands that the treatment time guarantee that SNP ministers legislated for in 2012 has never actually been met. Today, SNP ministers in this statement are publicly accepting that they have failed to deliver on pass promises made to Scottish patients. What is key is that SNP ministers understand that delivering a sustainable workforce is critical to this. Today, the cabinet secretary states the intention to create an additional 2,600 extra nurses and midwifery training places. Again, the fact stands that in Scotland today 2,812 nursing and midwifery posts are vacant with 852 unfilled for more than three months—a 27 per cent increase on last year alone—and that more than 4,300 nurses left the service last year. Can the cabinet secretary outline what steps that are not included in this statement will address the growing workforce crisis that we have in Scotland? Does the cabinet secretary understand that we need to stop the bleeding in our NHS before we put new blood into our NHS and what will she outline for a workforce plan in the future, which is actually fit for purpose? Thank you very much. I thank Mr Briggs for his comments and his question. The action that I have outlined will indeed see progress, and this chamber has my absolute commitment that I will make sure that it does that. That is why it is deliberately phased and targeted. The commitment that I outlined in terms of additional nursing and midwifery places is a commitment that we have made as a Government. However, as Mr Briggs will know, we annually look at the number of training places that we need to put in place across a range of areas in our health workforce. As we do that, we take into account a number of factors, including expected retiros and numbers of staff who wish to work part-time. Now we have to take into account those that we will lose or not be able to recruit because of impending Brexit and a number of other factors, including additional commitments, that we have made as a Government, not least in the programme for government, particularly in respect to mental health and the use of nurses there. We will look annually at that commitment and look to ensure whether, at any one point, based on all that data that we have, we need to increase it year on year. He has my assurance that that is what we will do. The decisions that we will make for the 1920 intake will, of course, be advised to the Parliament and to the health and sport committee. I absolutely do understand the importance of our workforce. I value them above all else, because without our highly trained, specialised but, most importantly, committed workforce, then our NHS would not deliver the significant results that it does deliver, notwithstanding all the challenges that it faces. I will say two more things. First of all, the challenges that our NHS in Scotland faces are challenges that are faced across the world, but we in this United Kingdom are the only Government with a plan for workforce and to tackle those challenges. A number of plans starting before recess with our medium-term financial framework and working all the way through. We have a plan, we have a commitment and I am determined that we will succeed. Monica Lennon I, too, thank the cabinet secretary for prior sight of her statement. Scottish Labour will always welcome any additional support for the NHS, and it is desperately needed, Presiding Officer. Last week, an investigation by Scottish Labour revealed that, since 2015, there have been 1 million stress-related sick days in our NHS. Staff are at breaking point because this Government has mismanaged the NHS. All of us are grateful to the dedicated staff who work in our NHS, and they deserve better than this. So do patients. This Government gave patients a legal right to treatment within 12 weeks, however that law has been broken 150,000 times. Let's get this straight. Is it the Government's intention to keep on breaking its own law until 2021? Thank you, Presiding Officer. I thank Ms Lennon for her question, and I, too, welcome her to a new role. I look forward to our exchanges. I do not believe that it is either fair or accurate, or indeed particularly helpful to our staff in NHS to use hyperbole, such as we have just heard. If we look at our eye matters survey, then undoubtedly there are pressures and strain in our health service. Our workforce absence is higher than we would wish it to be, but we also have across all our boards significant satisfaction from our staff in terms of their working conditions and their levels of involvement. If we could perhaps finish Ms Lennon, they know as I do that there are pressures and challenges to be addressed. Indeed, the workforce plan and the plan that we are looking at today are the product of work with those staff themselves. I do not accept the hyperbole that is too often used. I am disappointed that Ms Lennon is not congratulating me on not abandoning the targets, which I think was a concern that I certainly read about in this morning's press. I have no intention of abandoning our targets and every intention of meeting them. Thank you. I have 11 members and 11 minutes. That is a minute for question and answer if everybody is to get in. I cannot say it more bluntly than that. Ms White, no doubt, will set an example. Sandra White will follow by Alison Jordanson. Cabinet Secretary for Workforce, Planning and Staffing is paramount, has already been stated. If she believes that the implications of a no-deal Brexit will affect our ability to attack the special staff who need to realise the plan as a set-out today. Cabinet Secretary for Workforce, Planning and Staffing, of course it will, but the implication of any kind of deal in Brexit that does not involve the customs union and other freedom of movement arrangements will impact on our health service. It will impact on our health service because even at this stage in the proceedings we do not yet have from the UK Government agreement on mutual recognition of qualifications. I need to point out to members that what that means is that we could lose staff just now who want to stay with us, but we have not yet reached that agreement at a UK level in terms of the existing qualifications that they have. The pilot programme for registration, where the UK Government is not extending that to families of healthcare workers, is one that will also significantly encourage people to feel that they are not welcome here. We have been very clear about the welcome in Scotland and, indeed, today have offered with the Welsh Government to pilot a programme of registration support that includes families as well as healthcare workers. Thank you. Alison Johnstone, followed by Alec Cole-Hamilton. Thank you. Thank you, cabinet secretary, for early sight of her statement. Do any of the proposed changes to the current targets and indicators reflect Sir Harry Burn's recommendations for a life course approach to help to ensure a more preventative focus in our health system? Can the cabinet secretary assure the chamber that the needs of children and young people within our pressurised healthcare system are adequately reflected in the plan? I thank Ms Johnstone for her question. If I could answer the second part of it first, yes, I can give you the assurance that the needs of children and young people of all our population are reflected in the plan. I mentioned in my statement the work of the access collaborative, and one of the tasks that I have given them is to consider in some detail the work of Sir Harry Burns in terms of how we take forward the means by which we can determine where our health service is successful and where improvement is needed. That should not, however, deflect us, and I am not allowing it to do so, from the work that we need to do to meet the targets that we are currently committed to as a Government. Given that the Government's own improvement plan suggests that, this September, we posted our worst-ever performance against the waiting time guarantee, does the cabinet secretary recognise that the cruelest aspect of this is that every one of the 31 per cent of people who will have missed that target will have received a letter saying that they would have been seen in 12 weeks, and does she agree with me that it is time to review the management of expectations in our patients so that we can be upfront with them from the outset about just how long they will have to wait? Cabinet secretary, I thank you to Mr Cole-Hamilton for his question. I would not personally describe it as reviewing the management of expectations, but where there is a need for significant improvement is how our boards communicate with those who are seeking treatment in order to be as upfront with them about what the board is able to do as we work our way through this plan. We will make sure that boards are reviewing the communication that they give patients and that they are consistently communicating with individuals rather than having patients having to get in touch with boards themselves to find out what might be going on. Emma Harper followed by Brian Whittle. The cabinet secretary has mentioned the use of attend anywhere programme, which is being utilised in a number of areas, including in Wigtonshire in my South Scotland region, to allow virtual attendance for patients to speak with medical professionals. Can the cabinet secretary set out when that will be rolled out across Scotland and whether she believes that that will reduce the need for a number of outpatient appointments? We plan to commence the wider roll-out of attend anywhere across the country in December this year. It is being implemented in a way that is specific to try to remove the need for some outpatient appointments and to alleviate pressure, particularly on individual patients who might otherwise need to travel to meet those appointments. There is clearly a need dough, and the pilot programme has demonstrated to us that it is entirely clinically safe to do so. There is a need to ensure that you offer that opportunity to patients where it is clinically safe for them to do so. It is on the basis of the success of the pilot programme that we will roll out from December. The Health and Sport Committee report that the Government has made limited progress in reporting budget allocation against the nine national health and wellbeing outcomes. Does the cabinet secretary agree with the committee that there needs to be a greater link made between investment and delivering quality health outcomes? If so, how does she intend to redress the lack of transparency? I thank Mr Whittle for that question. I agree that there needs to be greater clarity in terms of our investment and where it goes and how that links to those quality health outcomes. To our overall approach of safe, effective and person-centred care, particularly with respect to that plan, we will make sure that members understand how the additional investment that I outlined earlier will be used to deliver the actions of that plan. We are currently reviewing how we deal with those matters, and I hope to be able to come back to the Health and Sport Committee and respond to some of the issues that it raised in that regard. The cabinet secretary will be aware of certain press reports today that a range of targets would now be getting withdrawn. Given her comments today, what will the cabinet secretary be doing to reassure patients and staff that she has no such plans? Thank you for the question. I will be saying it loudly and clearly starting here. I have no intention of withdrawing the targets and every intention of meeting them. I will say that here in this chamber, I will repeat it in any media commentary, and indeed it is very clear in the news release that we have issued. The plan itself speaks to that. We have no intention of withdrawing from the targets that we have set and we intend to meet. David Stewart, followed by John Mason. Presiding Officer, the cabinet secretary will be well aware that well-respected economist Professor John McLaren has concluded that the NHS will face an annual black hole of up to £400 million, rising to £415 million a year in 2023. Is there anything in this afternoon's statement that would fundamentally change the above analysis? Well, let me start by saying that I fundamentally disagree with the above analysis, and let me give Mr Stewart, thank you to him for his question, some of the reasons why I do so. I will be brief, Presiding Officer, and I am happy to follow up in greater detail. Mr McLaren's reference point is a publication in May. It is a publication that makes various assumptions about what a modernised NHS would look like. A comparable figure in the financial framework is 3.5 per cent. That is a figure that is supported by the Kings Fund, the Nuffield Trust and the Health Foundation. It is entirely consistent with the majority of independent analysts, and it is based on anticipated demographic pressures greater than those included in Mr McLaren's assessment. I disagree with his assessment, and I believe that our medium-term financial framework that I set out before recess sets out very clearly the challenges, what we are doing to meet those challenges and the further work that is required in that regard. John Mason, Fawr but Annie Wells. The cabinet secretary mentioned the Golden Jubilee hospital twice in her statement. I wonder if she can say any more about the investment there and what increased capacity there will be. Thank you to Mr Mason for that question. Specifically, the increased capacity in Golden Jubilee from March 2019, an additional CT scanner that will provide additional 10,500 images per year. The throughput of cataract operations undertaken in the mobile theatre will be increased to provide another 600 cataract operations and additional 600 endoscopies between last month and March 2019 and an additional 1,200 for the financial year 2019-20. Additional general surgery activity will provide 250 more procedures and an additional 4,000 ultrasound scans per year from 2019-20. In addition, it is worth mentioning that 4th valley and Golden Jubilee have undertaken at least two to my knowledge shared appointments in terms of ophthalmology consultants, which is an example of working across boundaries and, indeed, working in a new manner better fitted to the needs of our patients. Percentage of medicine places that are accounted for by Scottish domiciled students has fallen to its lowest level in 10 years under the SNP at just over 50 per cent. Is the cabinet secretary satisfied with that drop and can she tell me how many of the additional 400gp training places as promised in the statement will be for bright young Scots from all walks of life? Those are additional training places that the Scottish Government will fund, and therefore those who fall within the eligibility of that funding will receive those places provided that meet the requirements of the medical schools. In addition, though, since we are on the subject of additional medical training, I did not mention and I should have done the SCOTGEM programme, which is a postgraduate programme, just begun over in the universities of Dundee and St Andrews, which offers specific training targeted at GP work in the remote and rural communities. There is additional measure, which has 55 students on it currently. If it proves successful, it would be one that we would want to not only continue, but increase in size, and we will target specifically those areas in terms of GP where we have particular shortfalls. Mary Fee fall by Stuart McMillan briefly, please. We know the impact that delayed discharge has. 43,913 bed days were lost in August. There has been a 15 per cent increase in the number of patients whose discharge has been delayed due to issues with their health and social care package. Integrated joint boards were set up to reduce delayed discharge. Can the cabinet secretary give the chamber a realistic date when that might actually happen? We have a number of joint boards, as the member knows, and providing a realistic date that encompasses them all, removes their capacity to meet local demand, which is why they are there in the first place. I probably would be accused at that point of central dictax, so I am not going to do it. I am sure that the member paid careful attention to what I said. I talked about whole system reform, and I also talked about the critical importance of increasing the pace. I have been doing that since June of this year, increasing the pace on integrated health and social care in order to ensure that we alleviate the pressures in our secondary and tertiary care system. We are working on that, but we are doing that in consultation, as is appropriate, and jointly with local authorities. I would have thought that that is an approach that members certainly on those benches claim to want us to do and would be one that they would applaud. Stuart McMillan, can the cabinet secretary indicate what steps have been taken to update ophthalmic services so that more can be done in the community rather than in acute settings? There are a number of steps that have been undertaken in terms of ophthalmic services. We now have a range of opportunities that are suitably qualified and clinically approved that opticians and optometrists can undertake, specifically in longer-term eye care issues, in the longer-term maintenance support for those with macular disorders and for other eye conditions. We are looking to continue, not only to continue that, but to roll that out, because that is part of the primary care development plans that each of those integrated joint boards have now submitted.