 Welcome everyone to the health, social care and sport committee's 16th meeting of 2021. I've received no apologies for this morning's meeting. The first item on our agenda is to decide for the to take items 4, 5, 6 and 7 in private. Are members agreed? We're agreed. Our second item today is an evidence session with Nick Finn, the director of public health science and medical, Public Health Scotland as part of our scrutiny of the provisional common framework on public health protection and health security. Good morning to Nick Finn. Thank you for coming along this morning. I guess that our initial question is what the changes will be that will be brought about by the framework and how that affects public health in Scotland? One is to improve the exchange of information between England and the other two devolved administrations. Try and pool data to look at research issues such as Omicron and its potential impact on people's health. By pooling our data, we get the answer quicker and in a more robust way. The third one is to look at our cross-border arrangements. Microbes don't respect borders. We've seen how rapidly SARS-CoV has spread globally in common with many other diseases. Making sure that we have good cross-border co-operation both within the UK and with the EU is going to be critical going forward. In the third area is to look at our research priorities and the common focus for research. Those are four potential benefits to the new ways of working. I don't think that anyone would disagree with the objectives, as it is the application where probably we need to do some further work. My colleagues have quite detailed questions, particularly about our role as a committee in scrutiny of decisions. Having looked at some frameworks in other portfolios over the course of the past couple of years, that role for all the parliaments of the four nations and their influence on the decision-making process or their knowledge of the issues. Are you able to elaborate on any potential there? Where does the Scottish Parliament and indeed the Scottish Government fit in the decision-making process? There are four tiers, if you like. There is what we call the Health Protection Oversight Committee, which is represented by the Scottish Government and Public Health Scotland, along with the other agencies and Government officials. We will meet to discuss and agree issues. The next level above that is where I attend to Michael Kellett, who attends for Scottish Government, and the other three health protection agencies and Government officials attend. That is a very strategic level. That will meet two or three times a year to agree the oversight of the plan. There is a third level, which is the English, Scottish, Welsh and Northern Ireland CMOs group. Fitting in to that is a ministerial group. Composition of that is as yet, as I understand it, still to be agreed, but it will be an important one for resolution. Everything that you have said makes perfect sense about alignment and responses to any public health threat, and we have seen that in action with Covid. However, should there be an instance where maybe one of the nations wants to have a different response for reasons that we do not know yet because we have to take everything as it comes? Does the framework allow for that? Yes. Clearly, there is still a degree of autonomy within each country. Wherever possible, consensus is the desired way forward, both from communications and communication policy and operational issues. However, as we have seen with Omicron, there are divergencies if you look at each of the four nations across the UK in how they have interpreted and responded. One of the key issues is that we have seen the health systems in each of the four nations diverge, and they are now quite different if you were to look at each one. I cannot see how you can have a very rigid approach. It needs to be flexible to allow to take account of the various systems. Presumably, the response to the Covid pandemic has informed quite a lot of how the framework has been put together. Yes. Discussions had started prior to Covid, because Brexit has been on the agenda for some time. Work had started to look at what that might look like. My understanding is that the Scottish Government and the agencies that existed before Public Health Scotland had appropriate input into that. I myself only started just under 12 months ago, so I am getting up to speed as quickly as I can with the issues and events in Scotland. I am going to move on to Deputy Convener Paul O'Kane. Thank you, convener, and good morning to all those joining this morning. I suppose that, following on from the initial question in conversation, my questions focus on international relations more broadly. I suppose that maybe you have said a scene about this topic. Will the approach to international relations that has been set out in the memorandum of understanding be required often? Is that something that you feel we will not? Before I moved to Scotland, I worked with what was Public Health England and the Health Protection Agency before that. One of my roles was the national focal point for the international health regulations and the national focal point for ECDC, which is the scientific advisory body for the EU. I am quite familiar with the processes involved in that. My understanding is that negotiations are currently on-going for a memorandum of understanding with ECDC, which would allow us access to various scientific committees, networks to share data both at the country level and across the EU. Those are all currently under negotiation and under discussion. One of the consequences, if you like, of the Brexit has been greater reliance on what we call the international health regulations 2005. That was established by WHO to allow the exchange of information on issues that are considered serious public health issues. It does not restrict to infectious diseases. That includes environmental issues as well. That has been the stable platform that has been used pending further agreement on access to what was called EWRS, which was the early warning and response system to which the UK was a member and to which Scotland fed in. We submitted our data directly into Europe. Can I follow up, if I can? Your sense is that, similar to your first answer, we would very much be aiming to have a more collaborative approach and an approach where we come to a consensus rather than perhaps having to look to what is in the letter of the memorandum of understanding when they come forward. Is it your sense that we would much rather be finding the consensus on those issues? As a national focal point, when I was in Cullindale, which is the sense of infectious disease surveillance, there was a tendency for the scientific expertise to rest within PHE. One of the things that I did at a very early stage was to start asking the devolved administrations to take leads in various areas. That is something that I would want to see developed in the discussion with the EU around the memorandum of understanding. I am not sure that we are quite there yet, because the current technical committee has got 15 representatives from UK HSA that has only got one from Wales, two from Northern Ireland and three from Scotland. There is some work about how we make sure that we are adequately represented in those technical discussions, but it is very early days yet. Collaboration is the way forward, I believe. If I may, convener, that is very helpful. The consensus approach and the desire to get it right from the start is really helpful. It is just a hypothetical way where, for example, we would not be able to get perhaps agreement between the four nations on an international treaty or an international concerted action. Is your view that we would need to invoke the kind of conflict resolution-type procedures, or would the UK Government seek to act unilaterally? I think that, in terms of the conversation that we have just had around consensus, that is certainly something that we would be aiming towards. We know that often we cannot always get that, so we are just keen to get your sense of that. I cannot really answer that. That would be a policy issue determined by the seriousness of the issue and how important it was. That would obviously be something that the Scottish Government would want to take a view on. I think that it would be at that level that it would be invoked. However, wherever possible, it would be trying to get a resolution at some other tier in this sort of administrative structure. I move on to questions about information sharing from Emma Harper. Thank you, convener. Good morning to everyone and good morning, Dr Finn. I am interested in information sharing. As far as we now have different scientific advisory groups in each administration. I am sure that many of the members will know each other. We probably want to pursue a collaborative process using non-legislative measures rather than legislative approaches, which is part of the memorandum of understanding. I am interested in how good is information sharing between all four nations. You have said that there are three representatives in Scotland but 15 in the whole group and only one from Wales and one from Ireland. How is information shared if there is a top-heavy approach in the UK and England compared to Scotland and Wales and Ireland? That particular example was the ECDC memorandum of understanding technical group. I mentioned it to illustrate where we have to be and what we have to do. I want to make sure that that mix included some of the expertise that we have in Scotland. It is early days and the first meeting of the health protection committee only took place a couple of months ago. It is very early days. There is a recognition. I know many of the people well. It is not a case of relying on who you know, but I know them and they genuinely want to collaborate. I think that it is about having those discussions. If, of course, we get them further, we will have to sort of escalate that appropriately. As a former healthcare nurse in the operating theatre, I am keen that clinicians, scientists and experts all work together, because knowledge sharing is how we are going to tackle the pandemic and any future concerns to suppress any future pandemics. I know that we even have a pandemic committee that is being established in Scotland, so we have lots of experts around the table. Are we good at information sharing at the moment? How do we avoid duplication if different people are doing the same pieces of work, for instance? How do we prevent that kind of duplication? It would be fair to say that I could look around and identify probably some areas where duplication is currently occurring. That is probably a reflection on where we are with the development of the common framework. One of the key elements is a common understanding on research and trying to identify areas where one country might take a lead or other countries would come together to support it. We are not there yet, but it is something that we need to look at and ensure that it is addressed. There is a tendency that, if things are not addressed at the outset, it can sometimes be forgotten. I think that it will be important that we make sure that we are involved at an appropriate level and that we are contributing in a meaningful way across the UK. Just a final question, convener, if that is okay. If we are looking at surveillance and different data, I think that it is necessary to compare numbers of Covid cases and types of people's behaviours that may have led to outbreak, for instance. Sometimes we hear of people who are against wearing face coverings, for instance, or part of the data. If we are looking at surveillance in the different parts of the four UK nations, are we able to make informed, good, comparative decisions that show that one way might be a better way than another to help to inform the best way to deal with the pandemic? I can give you a couple of examples. There is a project called SIRIN, which is a piece of research work that Scotland is punching above its weight in, because we are contributing about four and a half or five thousand individuals to support the SIRIN study. The SIRIN study is looking at infections in healthcare workers, the impact of wearing personal protective equipment and looking at reinfection and vaccine effectiveness waning over time. It is a good example of where we are working collaboratively. Another example is where, for instance, for the new Omicron variant, we are agreeing fairly rapidly across the four countries a common case definition, so that we are comparing apples with apples, rather than apples with oranges. There are slight challenges, because clearly with the divergence of the way that the health services have developed, how data is collected, the timeliness of it and the data that is reported present slight problems with getting a truly accurate representation. Wherever possible, we share common case definitions that make the sort of comparison that you are describing possible. On that topic, I assume that you are quite happy for me to pass on to our colleagues to ask some supplementary questions on that. Thank you, Kaphina. There are many research and cancer databases that Scotland and England have—or Scotland does not have and England does have—and if we were to combine and work together, we would have a much larger pool of data and a far improved set of data. An example of that is the fracture liaison service database that we do not have here in Scotland at the moment, but we do in England. To me, it makes sense to join and have a big database, so will that encourage more shared databases and more shared work between our nations? The focus of the MOU is around health protection, so fractures would slightly be outside the scope of the current MOU. I have no reason to see that that could not be developed over time, but at the current time the focus is health protection. Therefore, what you are describing would be outside the scope of it. Having said that, the more sharing of data we can achieve, the quicker we potentially identify issues and problems, and the quicker we identify beneficial treatments. Data sharing is something that we should be pushing. There is an organisation called UK HDR, which is a research organisation across UK. In fact, it has been contributing to giving Public Health Scotland funding to look at how we improve our infrastructure or our information technology infrastructure so that we can share data with clinicians, researchers and valid researchers across the UK and even internationally. There is the embryonic start of the initiative about greater sharing and, certainly, IT capability. It is something within our grasp that we are making sure that we comply with GDPR, which is the general data provision regulations, and that any data is handled appropriately. I fully support that, but currently the health protection MOU would be outside the remit of that particular area. Nice to see you, Mr Finn. I have certainly had a lot of correspondence in my inbox about the secondary breast cancer audit, which the Scottish patients are contributing to. That last question from my colleague was very pertinent. I will go back a little bit in terms of what are the key lessons in terms of key changes in policy divergence that the four nations have learned from the current pandemic and how we have handled it in the past? Are they reflected in the framework? I am thinking mostly in the context of the Scottish election study that came out last week from the University of Edinburgh. It said that there was a poor understanding of the Scottish Government's facts and messaging versus the hand-based messaging that came from public health England. Given that sort of context, given that we have heard of collaborativeness and the consensus that we are seeking, do you think that we might be a bit more aligned going forward? I think that it is very early days. The first meeting of the health protection committee was in October. That is really agreeing a work programme. The work programme has identified 11 areas. One of those is about reviewing disease notifications across the four nations, and Scotland and Wales have been allocated the lead for that. Other areas include things like health protection, development of workforce, education, etc. Communication is not on that list, but one of the key messages for me coming out of the Covid pandemic is that we need to pay more attention to the behavioural aspects of getting messages out. I was one of the incident directors in public health England during the Covid pandemic response. At a very early stage, we recognised that assumptions that were being made about communications were perhaps not borne out by the research that has been undertaken by many of the behavioural scientists. One of the key messages was to utilise behavioural scientists and the information that they have developed in a way that helps to get those communications across. I was not in Scotland at that particular time, so I cannot comment on the approach that was taken at that point, but having those insights from behavioural scientists is key. The pandemic committee has been established in Scotland. There are one or two important behavioural scientists on that committee, and it is something that we are aware needs to be addressed. Can I move on to, as I trailed her, Gillian Mackay, when we ask some questions around consultation and scrutiny? Consultation on the framework took place. What issues were raised by parties during the consultation and have those since been addressed? Unfortunately, I am not able to fully address that. Many of the consultations took place prior to my appointment. If the committee wishes, I can try to identify that by speaking to colleagues and providing that information separately. As I said, prior to my appointment, I am not really unable to comment on that. It would be good to follow up with that, if we can at some point, convener. I know that the convener has touched on this a bit earlier, but do you think that the implementation of the framework will have an impact on parliamentary scrutiny and decision making in that policy area? If you do, what impact do you think that that would be? I cannot really comment on that. I am sorry. As I said, I am still familiarising myself with the current system. As I said, in the MOU, one of the proposals is to look at how ministers and Parliament are involved in that scrutiny. It is one of the issues that has been highlighted that needs to be addressed, but, as I said, the detail of that is not yet available and discussions are on-going. That seems to be an issue that I can take to our convener's group, because we have had common frameworks before us in the past year or so. There has probably been quite a lot of lessons that we can learn from that, which might inform how we feel about the way that scrutiny should happen, so we will take that away. On cross-border co-operation, I have some questions from Evelyn Tweed. Thank you, convener, and good morning, Dr Fin. Does Public Health Scotland believe the arrangements within the trade and co-operation agreement will facilitate adequate participation of the UK in controlling cross-border threats to or from its closest neighbours? It is an area where, prior to Brexit, we had extremely good relations with many of those new individual focal points within each of the countries. There was a system called the early warning and response system, which allowed member states to communicate in a confidential way with other member states to highlight potential issues and to even share information on cases of concern. That might be something like a case of tuberculosis that had left the UK, was untreated and therefore may present a potential hazard to the country that they were going to. The EWRS was a means of country-to-country communication, and it was also a means of informing WHO and ECDC figure issues and that wider information sharing. It is a gap that has not been fully addressed through the international health regulations, but I know that it is one of the areas that is being pursued in the memorandum of understanding with ECDC and is hoped that, very shortly, we should get access to a new version of something called EPIS, which was the epidemiology… I remember what the P stands for, but the information system, EPIS, would be called Epipulse, and that would allow timely sharing. We have access at the moment to EWRS for coronavirus and flu, and that is recognising the mutual benefit in sharing that information. It brings both to Europe and to the UK. However, if you were to look at certain maps of Europe and you were to look for the UK data or even the Swiss data, there is just a grey mark, so there is still some work to do to get some of our data integrated in a way that would allow that comparison, which can be very critical in understanding our progress towards controlling and responding to infections. In the same regard, do you think that there are any other gaps that we need to consider or that we need to strengthen moving forward? One of the gaps that I hope will be strengthened through this MOU is the scientific collaborations. We have been part of something like 16 special interest groups that would meet and come up with a common approach to some of the big infectious disease issues. Those two things, one, allow the standardisation of the data, and two, allow the common approach to some of the common issues. At the moment, we are not part of those, unless we have particular expertise that the EU wishes to access, but developing and being part of those networks will be really important in sharing that knowledge and coming to that common understanding. That is probably one of the other gaps, the participation in those expert networks. Was those networks in place as a result of collaboration across the EU, Dr Fin? Yes. They were supported and sponsored by ECDC, which would provide the secretary at host the meetings and facilitate the gathering of those experts to reach consensus of recommendations on specific issues in those 17-disease areas that Emma has been identified with. I come to Stephanie Callaghan. I realise that there are a couple of members who want to come in. Emma, you said that you had a supplementary question there, and then I will come to Stephanie. Apologies. Yes, please, convener. It was just a quick supplementary on similar to Sue Webber's question about hand-spaced space. We have Test and Protect in Scotland, and then it is back in trace or test, trace and isolate in England. I am interested in what work will be done or collaboratively about looking at whether TTI works or test and protect and people's understanding and adherence to the guidance. It is important that the message is achievable in order to help to tackle the pandemic. I am interested in what collaboration you are looking at for the behavioural aspects of dealing with these important messages. In any sort of event like this, major incident or pandemic event, there will be what we call lessons learned and undertaken. In Scotland, we have already done some of that looking at having an internal focus, but one of the things that would be really important is to carry that out on a UK basis. I am not aware of any work that is currently being planned, but that is certainly something that could be picked up by the Health Protection Oversight or the Health Protection Committee itself. If it was felt that that would be—and I suspect that it will be—important in learning lessons for any future pandemics, there is the inquiry that has just been launched, the lead has just been identified in Scotland, and there will be the UK inquiry or England inquiry imminently as well. Part of that will be about understanding what was done and how well it worked in asking fairly detailed questions along the lines that you are suggesting. It would be better if we started that work before then, rather than waiting for an inquiry. We do not know when the next pandemic will be, and it is really important that we get those lessons to learn for any future event. If I can come to the final theme of questioning around the resources from Stephanie Hallhann. Thank you very much, convener. Good morning, Dr Finne, and thanks for joining us this morning. As part of the memorandum of understanding, the shared work programme must be delivered within existing resources. Do you feel that that is realistic, whether existing resources are adequate, and are there any circumstances where you feel that that could become challenging? An interesting question, because if you look at the health protection resource available in Scotland as a baseline, it is about 900 people. If you look at England, you are probably talking about several thousand. There is quite a disparity there. The three areas that Scotland has been identified to take a lead on within the programme that has been set by the Health Protection Committee is to review disease notifications, analyse the four nation working groups, and look at genomics, which is an evolving science, in terms of collaborations, co-operation, sharing of data sets and data information. Those are big pieces of work. Certainly, at the moment—I can only speak for public health Scotland—we would be extremely hard-pressed to contribute in a meaningful way to those pieces of work and reviews. Clearly, we would prioritise it because the review in a disease notification has not been done for over 10 years. There are some changes that review may benefit. We may be able to identify in a review that would help to improve things. However, I do worry that, if the current Covid response carries on, our capacity to adequately respond may not be optimal. That said, this is a collaboration between public health Scotland and Scottish Government. It is clearly how that work is divided will need to be discussed further. We do not seem to have any more questions from colleagues. I thank Nick Finffrey's time this morning with us. We are going to take a break and suspension ahead of meeting with the cabinet secretary at 11 o'clock. Thank you very much, Dr Finne. Welcome back to the health, social care and sport committees. Our third item today is an evidence session with the Cabinet Secretary for Health and Social Care as part of our scrutiny of the budget for 2022-23. I welcome to the committee, Humza Yousaf, the Cabinet Secretary for Health and Social Care, who is joined by Richard McAllum, the director of health, finance and governance for the Scottish Government. Good morning to you both. Cabinet secretary, I would like to ask you a broad question about how the budget that is in front of us today starts to put in place funding for the Government's manifesto commitments from earlier this year. Thank you very much, convener. First and foremost, good morning to all of you and all the members. I hope that you are all keeping safe and keeping well. I am pleased to be at committee, of course, as always. It is a shame that it has to be done virtually given the constraints that are upon us. I look forward to being with you face to face. It is interesting that the question that you asked is a really good one. The budget that we have put in place helps us to build upon the manifesto commitments that we have already achieved this year. It is important to recognise that, in the first 100 days, we have already made an incredible amount of progress in meeting some of our manifesto commitments, abolishing dental charges for under 26. That went even further beyond what we promised to do initially in the first 100 days. Introducing the 10,000-pound bursary, which I know members right across the committee were very supportive of, putting in place the first steps for the national care service. I will come back to that in touch upon that. Many other commitments that we managed to bring forward in the space of 100 days, including, for example, the pay rise for not just the tenure for chain staff but also doctors and dentists too. There is a law that we have done in this financial year that we hope to build upon for the next financial year. The budget goes into great detail. One of the key significant reforms that we hope to be able to progress and take forward will undoubtedly be the national care service, which will be the biggest public sector reform in the devolution INA. I suspect that it will be fully operational by the end of the Parliament, but we are putting in place some of the appropriate building blocks for that. Also, crucially, we have funding to help us to progress with the national recovery plan that increase that you have seen to boards, which I can go into detail of if necessary. That helps to drive us in terms of that recovery, because we need to make sure that we are recovering, as well as dealing with the effects of the pandemic. There is a lot of work in resource but for brevity. On capital, there are important projects that you can see in the capital allocation. Whether that is Parkhead health centre, the virgin anchor project, the money to progress the replacement of Monklands, which is of course much needed as well. The big uncertainty continues to be the lack of transparency from the UK Government in relation to Covid funding. We desperately need that, because, as we all know, this is being conducted virtually as testament to that that we are not through the pandemic yet. Thank you. Gillian Mackay is going to ask for specific questions on Covid-19. One of the things that is obvious when you look at the budget allocations is that the Covid-19 spending last year is significant this year. There is nothing against that. Obviously, there is some confusion to put it mildly about the allocation of money that is coming from the UK Government announcements made last week. However, there has been a dispute over whether that is money that has already been allocated and has already been accounted for in the budget or whether that is money that is still to come. The health budget has an impact on the health budget, because presumably that is going to be allocated to things such as the vaccination booster programme. Can you give us some clarity on what is happening there? I wish that I could, convener, I suppose, which is the exact point that you are making. I will not delve too much on what happened last week, but it was extremely poor that, in the midst of a global pandemic, or at the foothills of another wave, when the First Minister stands in her feet, there is a press release from the Treasury claiming that there will be new money when there is nothing of the sort. Not only nothing of the sort, but a potential reduction in the consequentials that are coming our way. Those consequentials are vital in being able to, as you rightly say, deal with the effects of the pandemic. However, crucial the tools that we have in our armory against the virus, such as vaccinations, testing and protect, those consequentials are so vital to making sure that we are best equipped to deal with the virus. The Covid consequentials were far fewer, far less than we had expected them to be, given how much has already been spent in fighting the virus and the fact that the virus has not gone away yet. We really need desperate certainty from the Treasury about the amounts, about how we think that will be spent. I push, as you can imagine, the Secretary of State for Health and my regular Four Nations calls on this, as do frankly the Welsh and the Northern Irish. In fairness, he has always constructed in these conversations, but there is no clarity forthcoming, and that is deeply concerning and deeply worrying. I do not know whether my official Richard wishes to add to that, because he is involved, as you would imagine, in official-level discussions with finalist colleagues. Just a couple of things to add on the 22-23 position and where we are going into next year. As the budget sets out, there are not any formal consequentials that have been agreed for next year or for Covid-19. There are probably two critical points. One would be clearly in the money that we have agreed for the health portfolio. There are a number of things that we are taking forward to respond to the pandemic. The money that we have invested in waiting times improvement is a direct consequence of the pandemic and investing that as well as we can. The money that we have put towards social care is designed to support the overall system, partly in view of the pandemic. It has a longer-term impact as well. We are doing what is in our power and what is in our gift to make those decisions now. The point that the cabinet secretary makes about the on-going measures in relation to test and protect and vaccinations and PPE in particular is the key areas that we are working as closely as we can with the Department of Health and Social Care and Treasury on, because they are the areas in which we are likely to continue to need significant spend and where the clarity at this stage is not quite there. Some of that is understandable because we do not know what the future is going to hold, but I think that they are the areas where the certainty is probably most greatly needed. Thank you for that. Obviously, colleagues will dig into that further. In particular, as I said, Gillian Mackay has questions around Covid-19. The programme for government sets out those longer-term spending commitments, but there is no medium-term framework in place. I guess that it is understandable that we are dealing with a very acute situation, but in terms of giving us some information for our scrutiny, there will be more evidence coming forward about informing decisions on the allocation of increasing budgets. We want to keep our eye on things such as the £2.5 billion that has been promised over the course of the Parliament and the balance of care in terms of front-line health spending of 50 per cent. That increase for primary care by 25 per cent. Can you give us any idea of medium-term plans? It is a fair question, convener. As we already recognise, health and social care medium-term financial framework will have to be updated in light of Covid and other significant changes such as our work towards a national care service. The framework considers available resource and demands, but what it does not do is set a budget, which is informed by the key policy priorities and the national performance framework, and to ensure that those commitments are linked budgets that ultimately contribute towards the delivery of those desired outcomes. There was a recent study done by the LSE and the Lancet that suggested a 4 per cent real-term growth in healthcare costs is to be expected to ensure improving quality of care in terms and conditions for health and care workforce. That is very much in keeping with the assumptions underpinning the current medium-term financial framework. Of course, that as well as other independent research will no doubt inform our view, but there is no doubt at all that given the pressures and the challenges of Covid, we will have to look at that medium-term framework once again. Cabinet Secretary, you spoke a bit about the lack of transparency and we also mentioned silly political gains, so I am just wondering how you would then tackle something that has come from our own auditors. Audit Scotland has called for greater transparency in particular around the Covid spending and that the Scottish Government needs to have a more proactive approach in showing where and how that money has been spent. I am sure that that relates to the underspend of £292 million in the health and support budget. We have also heard, in response to that, from SNP members in Westminster and also your finance secretary, that the money has been carried forward. I was just a little bit concerned about that transparency when it comes to Covid spending, that we only see one line and it is not broken down into any sort of level of categories at all for last year. That subsequent carry-forward is not apparent anywhere in any of either table 1 or table 2 that I am looking at today. I am just wondering where that carry-forward money is sitting in the budget that we are looking at today. We will always look at any Audit Scotland report in greater amount of detail and give consideration to the findings. You might have seen that the finance secretary addressed some of the issues in the Audit Scotland report. It was important to say that, on resource, it was very well documented last year that very late consequentials in the past few months of the year would have to be carried forward to ensure that vital programmes could continue, such as vaccinations. Vaccinations do not stop at the end of a financial year, for example. We have a budget for the full initiative. On capital, there is no doubt that lockdown had an impact on projects being able to be completed in the timescales that they had. On portfolio, one of the most affected is transport and infrastructure. Contrary to any claims, the economy budget was overspent. It is important to digest the full detail of what was in the Audit Scotland report in terms of transparency in the budget. I am always happy to take any consideration that members may have about how we can be even more transparent than we are currently. On that, I will perhaps bring in Richard McAllum, who might have more details, if there are any specifics that Ms Webber wants to know about as she can come back in response after perhaps Richard is able to come in. Richard McAllum, as the cabinet secretary said, in terms of the information that we provide to Audit Scotland and others, I would certainly want to be as clear as we can in terms of not just all the Covid monies that we have spent but our whole portfolio. I am in regular engagement with Audit Scotland every month to update them on our financial plans and to talk them through our position. We will continue to do that. I think that, as a general point for this committee, if there is more information that is required on either specific funding lines or the general budget position, we would absolutely want to provide that information. In terms of the specific point about the underspend at the end of 2020-21, it was £292 million for the portfolio, and that relates to two things. As the cabinet secretary said, the first thing was just the timing of consequentials. We got some confirmation of funding in January of 2021. Just in terms of time to actually use that as well and as efficiently as possible, it meant bringing that into the new financial year. That was the bulk of that. The second aspect, and it is a bit more technical, but it was in relation to PPE. We agreed an approach with Treasury that we would, for Treasury purposes, account for that on cost. For the purposes of the Scottish Parliament budget, we showed that by way of stock held. It is a bit of a technical accounting thing, so I can provide more information if needed, but that increased the underspend as a result. It was something that we did in agreement and alignment with Treasury on that. Because that money was then carried into 2021-22, that is why it is not showing on the face of the 2022-23 budget, because it carried into the current financial year rather than the future financial year, which is what the budget is looking at. Thank you. Now we are going to go to health board budgets, and we have got Sandesh Gohani. Sandesh Gohani, thank you. Thank you, thank you, convener. Thank you, cabinet secretary. NHS Esher and Arran overspent on previous budgets as have a number of different health boards. In particular, with NHS Esher and Arran, there is also looking like it requires significant transformational change, particularly in acute services. That, to me, is a bit of a worry given where we are at the moment. My first question is, will you be writing off the overspends on budgets previously with the other health boards? The second question is, will you be looking at NHS Esher and Arran with the significant transitional changes that are required and what is being done about that? I can thank Sandesh Gohani for his questions on NHS Esher and Arran. I am certain that he is no doubt aware of that, but, of course, they remain at level 3 on the escalation framework, which is a very serious position for them to be in. That is very specifically in relation to the financial management. We continue, as you would imagine, in line with level 3 escalation, to undertake support scrutiny in line with that framework. Of course, financial recovery remains a priority for those boards. The focus has been on the response to the pandemic, which has undoubtedly impacted on their financial recovery plans. We are keeping regular dialogue with Ayrshire and Arran. As you can see, in relation to the budget in front of you for 2020-23, they are also in receipt of additional funding and finance, but we put some additional monitoring in place for those escalated boards. Ayrshire and Arran is one of them. There is another couple to ensure that there are appropriate steps being taken in terms of cost improvement, in terms of efficiency in advance of 2022-23. I remain concerned about Ayrshire and Arran, also about the boarders. Highland recently is also subject to section 22 in relation to finance as well, so it has continued to have those concerns. Cabinet Secretary, would you be looking to write off a proportion of the debt that the health boards have accrued? I wish to come in and add more to that. For me, we will work closely with the boards in terms of how we can support them. We want them to get into a financially sustainable level. Governments, for example, are writing off debts, whether they are for health boards or other boards. There are always matters that we would consider, but it comes at a cost to someone else in the health budget to be able to do that. With every penny allocated, that becomes incredibly difficult. We want Ayrshire and Arran—in order of Scotland, I am sure—to be able to stand in their two-feet financially viable and have in place those financial mechanisms and controls that can get them de-escalated from level 3 of the framework. Richard, I do not know if you want to add more detail to what I have said to Dr Gohani. A couple of things. Dr Gohani, that is a really important question. Over the course of the past 20 months, we have taken an approach with boards where we have needed to balance that on-going financial management and financial scrutiny with the realities that the health boards have needed to focus on the immediate of dealing with a pandemic. A transformation programme does not just happen in a finance department. That needs to be hand-in-hand with clinicians, with those who are working in the service. There is an important balance that we need to strike between asking boards to continue with that financial—goods financial management and scrutiny and transformation change but at the same time recognise the pressures that there are in dealing with a pandemic. With that in mind, we have taken an approach in the last in 2020-21 and, indeed, the approach will take this year where we will not provide in brokerage or will be supporting all boards with Covid funding, which will allow them to balance their financial position in this year, as all boards did last year. We recognise that there is an element of unachieved savings just because they have not been able to move forward with their savings plans as they might normally have done in the free pandemic. I think that the point that the cabinet secretary raised is about keeping those boards that were financially escalated under enhanced measures. We are getting monthly reporting from those boards that show what they are doing by way of their financial planning. Whilst the pandemic goes on, that transformation work has not stopped. We have continued to discuss with the boards the steps that they have got in place. We have asked all boards for three-year plans, service plans and finance plans for 2022-23 and beyond. That will tie in with the spending review when that comes in in May. That is when we will be looking to get greater assurance and certainty about boards' financial plans moving forward. I have one further question. I was looking through the details of the money that has been provided to the boards. Distinction awards look like they have come down. Are we still giving out new distinction awards, or has that been phased out? No, I do not think that we are giving distinction awards, but again, Richard, you might want to pick up on this particular decision. Richard, again, you will want to provide clarity on that. That is correct. That is the right position. That is why money is reducing each year, because there are not new awards coming in. That budget line will continue to reduce, because there are not new awards being provided. It has been a number of years now that we have taken that decision. In the more detailed table, it said that the distinction awards are designed to provide competitive remuneration packages for consultants and ensure that we are trapped and retain the right calibre of employees. Without the distinction awards, how will we achieve that? There are other ways that we can try to recruit and retain. Under the Government, there has been an incredible increase in the number of medical consultants since 2006, which we are pleased about. I take the point about retention. There are a number of avenues that we are looking at. One is, of course, to make sure that they are well remunerated. The other option that we are looking at is pensions. Some of that is in our gift, but a lot of that is in the UK Government's gift. I have been having discussions with the UK Government about potential pension changes. You probably know—I think that you may be a member of the BMA, of course—that the BMA has written to me to look at whether or not there is more that we could do from a Scottish Government perspective on potential pension changes, which would help with retention. There are a number of other avenues that we can look to, as opposed to distinction awards, which we have not been providing for a number of years. However, I will work closely with the BMA and others in order to ensure that Scotland is not just a competitive place to recruit more consultants, but to retain them, which is key to Dr Gohani's question. I am saying that Sue Webber wants to come in. I am just checking with Sue. I have got you leading on the theme of capital budgets. If you have got a supplementary question on health wars, you can just move on to your questions on capital budget after that. Thank you, convener. As representing NHS Lothian, I was again disappointed that the assistance from the NREC recommendations for NHS Lothian was £12 million. You have also spoken about how—Ritchard mentioned that—your prioritising funding for health boards is struggling to deal with the pandemic. Most of them are, to be fair, to some degree. When we see that the greatest percentages of increases are going to the national boards and not the local health boards, I am just—yes, the waiting time centres are there, and it is an elective plan service, but the ones that are really struggling are the ones that are struggling with A&E that have got the emergency admissions. I am just wondering what the decision was made about proportionately giving more to the likes of Public Health Scotland, National Services Scotland, Health Improvement Scotland and the Waiting Time Centre, rather than some of the health boards. Every health board is receiving an uplift, and that is important. I completely accept, of course, Ms Webber, that you will want to go out there batting for lowlion. Of course, why would you not give them the role that you have? But what I would say is that every single health board is, of course, facing a significant challenge. The A&E departments at the ERI, for example, are challenged when I look at the figures. But also, if I went across the A&E department in the Queen Elizabeth, or if I went to Forth Valley hospital or the ARI in Grampian, they are significantly under pressure and are significantly suffering. Therefore, our in-rack formula, plus the parity funding that we introduced to ensure that the boards are within 0.8 per cent of parity, can assist health boards right across the country. I would say that the funding to other boards, the non-territorial boards, is vital. You referenced the funding to Public Health Scotland. If you think about how crucial they have been in our fight against the virus in the last 20 months, I do not think that. I am certain that you are not doing this, but nobody would argue to take money away from Public Health Scotland and then decide to split it elsewhere. All those boards are important, whether they are territorial or non-territorial. We have record investment in the health service, which is £18 billion the first time that we have ever been able to finance health and social care to that level. Significant amounts of funding—what I would say to Sue Weber is that I can give an absolute promise and guarantee that I meet Lothian on a very regular basis. I have a great amount of faith in the management team, the chair and the board to be able to put that money to good use to help to improve what is a very difficult situation right across Lothian. Thanks, cabinet secretary. I have a great admiration for NHS Lothian as well. You mentioned in terms of the capital budget. You specifically mentioned the Beard and Anker project and Parkhead and Health and Social Care Centre in Glasgow. In the past, I have always had it levelled at me that there has only perhaps not been the level of investment in building that new GP infrastructure across the country, and you might get one significant GP practice funded in any Government term. Will more detail and how that might manifest come in the if the capital investment strategy plan is published and when might we see that? It is a good question to ask. As you can see from our funding, the Beard family hospital on the Anker Cancer Centre will invest significant amounts of money, more than £120 million, which is important. You will also see from that capital a significant amount of funding, more than £30 million a year for Parkhead, which is actually the biggest investment in health and social care centres. That is the model that we want to try to move forward with where it works. It is not appropriate everywhere, but certainly in those health and social care centres we know that we can get the appropriate support in one place for the public that we serve. They can be exceptionally helpful, particularly the point that Sue Webber was making before, particularly to try to reduce that demand at the front door and at our acute sites, which is going to be really important. In addition to that, we have committed through our manifesto to spend £10 billion on health infrastructure over the next 10 years. That is a very ambitious target, so we are going to have to make sure that we profile that appropriately over the space of the decade. In terms of the specific question that she asked about the capital investment strategy, you are absolutely right that that is going to be key to some of the important funding decisions. We had tended to publish it after the Infrastructure Commission for Scotland published its report, and that was in the 20th of January 2020. However, of course, we have all been focused on the response to the pandemic, so we do not have a date to absolutely nail down, but I can promise her that the strategy will be published as soon as it possibly can be, because Ms Webber is right that it is an important document that is going to give people at least some comfort in the assurance that important capital projects have been taken forward. Thanks. On the £10 billion that you have sent, cabinet secretary, about refurbishing health infrastructure, I ask whether that includes technology that is within the hospital infrastructure specifically, and we are talking about capital, whether it be theatre tables, new theatres, buying newer and better capital. With an experience that I was aware of in Glasgow specifically, the hospital wasn't able to buy a new theatre table or certain pieces of equipment, but it was able to lease it at £2,000 a time, which did not make much sense to me when you look at the number of times they were looking to rent something versus the overall spend, so I am just trying to gauge what might be able, because I know that the level of capital that is getting down to that granular level is not always significant enough to invest in what is needed for services. We have not made any final decisions on how that money will be earmarked yet, so we have not given full detail of that. Obviously, we have to look at what the health board wanted to fund and whether it could be financed through capital or whether it could be financed through resource. If there are specific examples, as you mentioned, a theatre table is there. Of course, capital projects are important investments to make, and we need to give health boards the ability to make sure that they renew their equipment where possible. However, the real focus on our capital infrastructure programme will be on significant refurbishment and replacement and build of assets, but Richard, I do not know if you wish to come in on the specifics around theatre tables being— That is an example of theatre tables, cabinet secretary. No, I know. I think that the point that you are making is important. I am genuinely not focused on the big projects, but there is a question there about some of the smaller things. It is a really important point, one specific example, but what I would say is that, as part of that capital strategy that we look to bring forward, that will include an equipment replacement programme, because we know that that is a challenge and a risk for health boards to make sure that boards are working forward with a clear plan and design for those things. We have worked with all the territorial boards over the course of the last year to look at their equipment replacement plans. We have built that into the workings that we have done as part of the capital investment strategy. Paul Kane has a supplementary question. Thank you, convener, and good morning to the cabinet secretary. Just following on from that point about that £10 billion investment over the next decade, given that health capital budgets are typically around £500 million, it is clear that there is going to have to be quite a detailed upgrading of that budget, so I am keen to understand where the cabinet secretary thinks that that will come from. Within that, there have been a huge amount of capital promises made, whether in the plan that is not yet published, or in the manifestos, for example in my own region, refurbishment of the RAH, refurbishment of Vela Levine hospital. We know that there is a £76 million repair backlog already at the RAH, so I am just keen to understand how and when we are profiling those things. That is a very fair question, and I suppose that some of it goes back to what I said to whoever. Given the capital infrastructure projects that we have, which we currently are dealing with, for example, the biggest one that is in my entry at the moment is the replacement of Monclans, we suspect that most of that money is going to be disposed and back-loaded to the latter years of that 10-year spend, but that is why I appreciate the capital investment strategy for giving me for health is published sooner rather than later. Given what I have said to Ms Webber already, I probably do not have much to add other than to say, I hope, for understandable reasons, that people understand why that was delayed, but I also accept their challenge back, which is that they need, as elected members, some certainty, so I can give them a guarantee that we are working on the investment strategy and that we aim to publish it as soon as possible. Thank you. We move on to questions specifically around Covid-19 health spending in Gillian Mackay. Gillian Mackay, thank you, convener, and good morning, cabinet secretary. Given the new variant, have the estimates and identified funding allocation changed 2022-23 budget? It is a developing situation and undoubtedly well, and I suppose that it goes back to my initial remarks to the convener, which is that we are perplexed by the level of Covid consequentials and Covid funding that the UK Government has put on the table. It may be that that is its initial estimate, but then it gets lad to that as the circumstances dictate, but for us, it is deeply concerning in the Omicron variant, without a shadow of a doubt, adds financial pressure. Gillian Mackay is very aware, because I have heard her speak in the chamber on this, that, of course, with additional resource, we could potentially go further in terms of measures to take and compensate business that are already suffering, even with the guidance and the advice and the regulations that are currently in place. There are getting cancellations by the thousands, and that is a serious financial impact that comes with that. There is no doubt that Omicron, if there is to be another variant, which we could not discount, that is going to add even more financial pressure, and therefore that clarity is much needed. Obviously, we have already spoken about the lack of clarity on additional funding coming from the UK Government. If there was additional funding to come, how would you envisage that being diverted to different parts of the health service? Again, part of it would be to give more financial compensation to those sectors that have been hit and hit hard. Gillian Mackay will not pre-empt what the First Minister has to say in the next couple of hours, but it would be fair to say that, even as the position is at the moment, there is no doubt that not only has the hospitality sector been hit hard, but the event sector, for example, has been hit hard, the culture sector has been hit hard and so on and so forth. If we had some greater financial certainty, we would be able to act in a way that we thought was in the best interests of Scotland. Again, that is not just a kind of Scottish Government position. The Welsh Government has said similar in a different political party, where the decisions that are appropriate to make for our country should not be constrained about whether or not we get additional resources from the UK Government. It should be that we take the decisions that are at the best interests of health in Scotland and the funding flows from the Treasury in respect of those decisions. Of course, bolstering and continuing to bolster test and protect in the vaccination programme is a key foundation block in our fight against this virus. It is always important that they are not being adequately funded, but we had to push just one example on that. We had to push the UK Government really, really hard in order for them to extend the contract for the Glasgow Lighthouse Lab, which has done an incredible job. The contract was due to run out in March 2022, and we were all getting anecdotal evidence that people were already potentially going to be looking for other jobs if they had no job security. The UK Government has now moved on that and extended the contract to September 2022, but it should not take us to have to keep pushing them in order to get that level of certainty. Just finally, given the emergence of the Omicron variant and the impact that will have on the recovery of the health service, how do you see that downing around recovery being allocated now that we have the new variant and the uncertainty around that? Just in no doubt, it causes more difficulty. The emergence of a new variant that is more transmissible means that we are facing even greater challenge. When a Omicron first emerges, and the member will know that, when the first clusters were found in and around the Lanarkshire area, we ended up in a position where entire departments in our acute sites in Lanarkshire were worried about staffing levels. They were able to cope and pay tribute to the management at Lanarkshire and the health board at Lanarkshire for being able to manage that situation, but it looked difficult and challenging at one period. The emergence of a new variant does not just have direct health impacts, which, of course, it does. We have to factor that into the recovery, but it affects our staff. There is now an exemption for the process in place for NHS and social care staff, but it is still a view or a positive case. Those positive cases are increasing, as you can see from the daily numbers of recent cases, and that is clearly still going to have an impact on the health service. I move on to Paul Cain's question about social care and national care service. To handle the figures in the text of the budget, I wonder if the cabinet secretary could explain the difference between the £1.6 billion figure that is highlighted in the budget and the £1.1 billion figure that is identified in the budget tables, which comes under social care investment. Can we try to understand the difference between those two figures and what is the actual spend? Let me just look at the tables that you are talking about. The explanation of that would be that they need to transfer from the health portfolio to local government. They are grouped together in the budget as a social care investment. The detail elements are then set out within the level 4 budget tables, which are available on the Scottish Government website. This is the total of the £1.1 billion. However, £1.6 billion is the overall package of investment in social care integration, so that comes from a combination of funding that has been baselined in health boards in local government and also from further Indian transfers from the health portfolio to local government. That is why there is a bit of seemingly discrepancy between the figures. Perhaps we can make that a little bit more clear. That is my reading of it, Richard. Is there anything in there that you want to add? That is correct, cabinet secretary. The 1.6 represents all the money that is passed from the health and social care portfolio to social care. About £500 million of that has either already been baselined in local government settlements or is part of an NHS board settlement that will pass through to IJBs. The £1.1 billion represents the transfer that will go across in the year, so that is the difference between those two numbers. I think that it would be useful just in terms of verse scrutiny if we can have some of that further detail perhaps written for committee just to take that forward. I wonder if I can, convener, just ask essentially about the structure of the national care service and whilst we are obviously still going through those responses and we do not yet have the structure finalised, there is of course the proposal to create community health and social care boards. It is essentially to replace IJBs. I am keen to understand if the cabinet secretary thinks that many of the issues that have been experienced with financial accountability and leadership in IJBs will be solved by creating a new structure. That is a really good question. The first thing that I would say is that there is no fate of complete here. I think that I said this before to the committee and I am not sitting here with a master plan of what the national care service will look like and then expecting the consultation process to just fit in with what my thoughts are far from it. We are genuinely interested in the analysis of the responses that we received and have received quite a number of responses. I am also genuinely very considerate of making sure that we do not create the system and then try to fit the people into it, but instead make sure that our system fits around the individuals. Financial accountability is hugely important for us as decision makers and policy makers, but it is hugely important for the individuals. I will not be the only MSP who has had to fight on behalf of a constituent because they have not received the package of care for a loved one or relative. Their fear is that the reason for that has been more to do with cost and finances than to do with the actual needs of the individual. My hope is that the structure that we end up putting in place—again, I just emphasise and re-emphasise what I have said—that nothing is concluded yet on that. If we go down the model of the creation of community health and social care boards, then absolutely financial accountability and I think that Paul Cain said leadership, those two issues have got to be central to the creation of a national care service, which is whatever structure we end up putting in place. Thank you. Paul, have you got one more question or can I move on? I do just have one more if I can just perhaps segue into the subject of pay for social care workers. The cabinet secretary for finance in the budget process said that she felt that the 48p increase was fair and that it pays carers for their labours, I think, was the expression. Would the cabinet secretary agree with that? Does he feel that that is acceptable in terms of the pay increase for care workers? What I would say to Paul Cain is that I know that he uses the 48p figure and I appreciate it if I was in his position. I might end up doing the same, but if you look at what that pay increase means for an adult social care worker over the course of a year, that is not something to be scoffed at. We are talking about almost an additional, just shy of an additional £1,000 a year. That is not the only pay increase that we have brought forward. I have brought forward his cabinet secretary for health. Of course, that comes on top of an additional pay uplift from £9.50 to £10, and then, of course, increasing that to £10.50. What I would say to Paul Cain is that, as we continue to be in this budget process, if he believes that social care funding should increase, for example, to £12 or £15, I am not sure what the current position is, but we would have to find that within the budget, which is allocated, and they do not come cheaply. I know in the chamber before, for an increase of £12 per hour, that would cost £420 million per annum, or £1.3 billion if we get to the £15 per hour. Even more, once improvements to terms and conditions are factored in, it could be up to £1.6 billion. Those are not small numbers at all. I absolutely take the point that our social care colleagues and adult social care in particular need to be recognised and valued, and that is why we have ensured that they get a pay increase in the pay uplift. For any addition to that, of course, let us have that discussion, but let us be upfront about where that money would come from. We will move on to preventative spend and questions from Evelyn Tweed. Good morning, Cabinet Secretary. It is good to see a focus on preventative spend in this budget. How is the Scottish Government ensuring that there is a joined-up approach to spending and outcomes across other portfolio areas? I think that that is probably the most crucial question that we can deal with at the moment. The preventative spend agenda is something that we have progressed as a Government for a number of years. It was something that was core to Christy, which is as relevant today as it was when the Christy commission was published. Therefore, for us, we can do everything that we want in health, but if we operate as a silo, then we are not going to make the difference in people's lives that we would want to do, so we have to make sure that we are working with our colleagues whom we are in education across social justice, justice itself as a portfolio, housing and the economy. Therefore, the work that the DFM does, where he brings us together on at least a weekly basis, with a laser focus on targets around child poverty, is helping us to work in a way that is even more collegiate than it has been previously. It will help not just us as decision makers, but I do not doubt that it will have an important effect and outcome on those that are very regrettably fallen through the cracks in the various systems that they get passed from pillar to post to, and that is just not acceptable. I think that there is good joined up working taking place between various different portfolios. Thanks for that, cabinet secretary. We have heard about all the pressures on the NHS and, obviously, we are in the midst of another wave of Covid again. How can funding for preventative spend measures be protected? I think that the two are linked in all honesty. You can again help people through Covid with the various spend that we have already put into the budget, but if they get their vaccine—take vaccinations as an example—we know from the data that we have seen that those, for example, in the most deprived areas, we know that the uptake can be the lost in terms of the vaccine. When we deal with preventative spend, when we focus in on child poverty and early intervention, that can even help us in our vaccination efforts in the future, not just for the current pandemic, but we have to be prepared for what the next pandemic might be. It is really important for us to not see the two as being distinct or separate, which I know that you absolutely do not. On protection, it would be fair to say that if you looked at our budget in detail, it delivers on that 50 per cent of front-line spend being directed towards community health services and progress our commitment to increased primary care funding by 25 per cent. We have a good basis to build upon, but those are difficult balances to get right in terms of the current pressures versus what is provided. However, I try not to look at them as completely distinct or separate, but our investment in preventative will help us in relation to dealing with the pandemic as well. Moving on to talking about shifting the balance of spend, we have questions from Emma Harper. Emma Harper is a good morning, cabinet secretary. We have taken evidence in previous health committees about shifting the balance of care and moving spend to be more preventative and away from hospital settings and more in the community. The Scottish Government has committed to shifting the balance of care so that at least 50 per cent of front-line health spending takes place in community health services. Given that this is in the budget, would the cabinet secretary think that this needs to be more ambitious or is 50 per cent adequate for how we are planning right now? I do like that question from Emma Harper. It is a fail one to ask. If we are already getting there, then are we challenging ourselves enough? I think that it is a fair and gauntlet to go down. For me, the purpose of the target is to make changes on the ground, but to underline the Scottish Government's focus on shifting the balance of care where it is possible, but also ensuring that we have appropriate support for hospital-based services. Nobody at all would be saying that those are sources, which is an important point. I know that Emma Harper has given her own personal experience and understands very well. We will continue to review the appropriate portion of the spending, which is going back to what I said previously to the convener. Perhaps we will take that into account when we get further details. I think that, in general, Emma Harper has challenged us as a fair one. If we are already meeting that target, we should be looking to be even more ambitious, so I will absolutely reflect on that. Thanks, cabinet secretary. I know that sometimes we have all the budget lines and top lines and different figures are just thrown out there. I am interested in the £15 per hour for care persons, because that is what a band 5, 3-year university-trained staff nurse makes. If we were going to challenge to move that spend or increase that spend, that puts another burden on workforce planning. That would be a concern for me. I am not suggesting that our social care staff should be supported and educated to have clinical expertise in progression. The £1.6 billion is an interesting figure that you have given us if that was to be the case for a £15 salary. I suppose that that would be an interest to hear your additional comments on that. There is nothing much to add other than that. Every single person around the committee's virtual table is in the same space when it comes to valuing the role that social care workers have played throughout the course of the pandemic. I say that it should not have taken a pandemic for people to realise just what a significant and important role our social care workers play. Saying that is one thing and rewarding them appropriately is another. In Government, we have a good track record. In the past 12 months, we have increased their pay from £9.50 to £10.50, and we have made sure that we are putting up the appropriate finance and funding for that. I fully appreciate that there are members across political parties who will say, we want you to go further. If that is the case, we have to engage in those budget discussions with the finance secretary, but you have to be able to tell us where you take that money from. Do we take it from other parts of the health service and other parts of social care? Emma Harper is right, of course, that it could have a knock-on impact on other parts of the workforce, which we would have to factor in as well. I am always up for this conversation on what more we can do to reward our social care staff. Let's just do that based on figures and what is available in the budget. Let's have a realistic conversation about where that money would have to be taken from if other parties want us to go even further. Emma, you can move on to mental health. I had one question about the progress towards increasing the primary care spend by 25 per cent. I think that the Government has a commitment to increase primary care spend by 25 per cent. I will make that my final question. Yes, we do. I was just looking at my tables. We are at about 6 per cent, so it is a good first step in that direction. Yes, you are right. We have that commitment. I would be confident of meeting it, and that is a good step in the right direction. We can now move on to mental health spending questions from Stephanie Callaghan. Thank you, convener, and good morning. Not afternoon quite yet, cabinet secretary. I can also just very quickly praise NHS Management for all of our hard work as well. I appreciate that NHS boards and integration joint boards often deliver mental health services that track and spend in Canberra, which is challenging, particularly on things that are outwith the health sector itself. I have a couple of questions on that. What evidence is being gathered to understand the impact and effectiveness of the additional spend? Secondly, how does that influence the future funding decisions? For example, the balance between adult services and child and adolescent mental health services? Both really good questions are intrinsically linked. I would agree with Stephanie Callaghan's opening remarks on the job that NHS Lanarkshire has done. They have not been without their challenges. There are a number of challenges that NHS Lanarkshire often faces, given its geography, but we are also given the pressures that are under its scope to handle the way well. We are working, as you can imagine, on a very regular basis with NHS Lanarkshire to try to see where we can get them de-escalated from the highest level of escalation that they are under. On the specifics that you ask about, that is a really good point about the effectiveness of the interventions and of the money that we spend. Any funding that we allocate is delivered against clear criteria. Those who are in receipt of that funding have to report on the impact of that funding and the outcomes that we agree on. However, we also engage with stakeholders on a very regular and on-going basis around the use of resources to deliver outcomes. What risks may be, because there can be unforeseen risks that cannot be accounted for in a funding application when it is received. As the member probably knows, we have committed to refreshing a long-term mental health strategy. That work will build on the evidence of success that we have seen from interventions and engagement with stakeholders and, quite crucially, from those with lived experience to identify what the future priorities will be. Of course, in turn, that will help us with what our funding priorities should be. The second part of the question from Stephanie Callahan, which is a really good one, is the balance between adult and child adolescent services. The first thing to say is that my goodness will have had what impact the pandemic will have had on all that, on adults and children and adolescent services. That is not to say that there were not challenges before I readily accepted that there were challenges before I would not again have been the only MSP on this call who would have had a constituent who was in need in the waiting lists and waiting time for CAMHS. It was far too long, and I am not going to pretend otherwise, but there is no doubt that that has been exacerbated by the pandemic. Our mental health transition and recovery plan that was published in October last year reviewed those priorities and decisions on the use of an additional £120 million recovery and renewal fund that is allocated to support of the delivery of that plan, based very much on an assessment of proposals that were set against those priorities. However, those were very much in discussions with key stakeholders. Those are difficult decisions to get right in terms of that balance between adult and child and adolescent services, but it is something that we are continually looking at and it is part of our recovery plan, NHS recovery plan, and ambitions are going forward to ensure that we get that balance absolutely right, but it is going to require significant investment going forward. That is great. I will follow on from that again. During the session that we had on perinatal mental health, we did hear evidence from Mums as well talking about the critical role that first sector organisations were performing locally. The expertise and support was an absolute lifeline, as far as Mums were concerned. In that session, we heard from third sector stakeholders, too, who were expressing some concern around the fact that they were losing a bit of their local specialism and expertise that makes a positive impact on the ground in local mental health services. My question is how can we have more secure long-term third sector funding and how can that be provided to support the mental health delivery by third sector organisations in the community settings? I concur with everything Stephanie Callan is saying. I, as you have imagined from a local MSPs perspective, let alone health secretary perspective, see the value on the ground every day of the third sector organisations and partners that Ms Callan refers to. From my perspective, I want to make it absolutely clear as the cabinet secretary for health and social care that we do not just value third sector organisations through our words alone but through our deeds and our 2223 mental health budget, which will increase by 6 per cent on the 2122 figure. This year, we have allocated a greater proportion to support community and third sector projects, including £15 million, for grass-roots community groups via our community's mental health and wellbeing fund, for adults to help to tackle the impact of social isolation, loneliness and mental health inequalities. On certainty for the future, I do not doubt that one of the asks that I and every single member here gets, which is for that multi-year budget, and the finance secretary has laid out some of the groundwork about how she would look to potentially do that for future years. That might provide that longer-term sustainable funding and outlook for third sector organisations in the future. We are not at that stage yet, but certainly I know that it is an ambition that we have in government. Thank you, Stephanie. Can I move on to talking about alcohol and drug services? Question from Sue Webber. Thank you, convener, and thank you, cabinet secretary. I did mention earlier about the Audit Scotland report saying that the Scottish Government needs to be more proactive in showing where and how this money has been spent in a generic budgeting part. I am looking for support and commitment that, in terms of the importance that we are all giving to tackling our drug-related deaths, can the Scottish Government now commit to publishing regular information that shows us the granular detail on how this money is being spent? In principle, I would have no issues with that, and I can look at what we are publishing at the moment and whether or not that would meet your expectations. We can have a discussion around that. In my letter to the committee, I did reference, in some level of detail, ADP income and spending for 2021. We intend to publish this information once the analysis is complete. We will provide the publication to the committee. Of course, we will do that. That will provide a level of detail on the income and spending of alcohol and drug services locally and what is provided in addition to the Scottish Government. However, if you looked at that and did not provide you with the level of detail that you were expecting, I am very open to having a further conversation about how we can provide that. We are just looking to get that sense of consistency across the country, which is a theme that we get from all our committees and just the variances that happen. In the budget, there is an extra £1.2 million increase in the direct Scottish Government spending on alcohol and drug policy. However, how does that relate? How has that come together with the commitment for the additional £50 million per year for the lifetime of the Parliament? I am just trying to get a sense of what the relation is. Maybe Richard might be better. I am more than happy to be Richard. In a second bit, it is fair to say that it is just to be absolutely clear in addition to that. The funding is in addition to the £61 million reducing drug deaths budget, which includes the second tranche of £50 million of additional funding as part of the £250 million commitment, which is obviously over five years from 2021-22. That funding is specifically aimed at supporting additional response to a collective challenge around drug deaths, which is an increase of £1.2 million, which is your reference on alcohol and drugs funding. For 2022-23, it brings a total budget to £24.4 million, and that includes investment in alcohol harm and treatment policy teams to deliver our alcohol priorities from Alcohol Focus Scotland, Scottish Health Action on alcohol problems in the Scottish Alcohol Counseling Consortium, and provides funding for specific alcohol services that will be able to be delivered to support the Simon community to deliver a pilot-managed alcohol programme. That funding is in addition to the £61 million reducing drug deaths budget, but I hope that that is clear. I do not know, Richard, if you have anything to add to that. No, I think that you have covered the £250 million over the Parliament. This is the second year of that £50 million each year, and that is covered in the 2023 budget. Thank you. Finally, it is, as I said earlier, that we are all across the chamber. Every party is back on this. We really want to make sure that the additional funding is breaking through and that it is not getting down to where it needs to. How will the additional spending be targeted to ensure that it is being used effectively in that way? Again, how are we going to measure that impact? What are we looking at to make sure that the money that we are investing is having the desired impact and saving lives? There are a slew of statistics that I have published very regularly, which I know that Ms Webber will keep a very close eye on, as we do, to demonstrate whether we are making progress in the area that we all want to see progress in. Monitoring and evaluation will be very much at the heart of what we do. The Scottish Government works closely with our alcohol and drugs partnerships to monitor the delivery of the national mission. That is a national mission, and any organisation that receives funding for drug services will always provide regular reports on the outcome. We will also work with those public bodies that are really vital to this, Public Health Scotland, Health Care Improvement Scotland, to understand what the bigger picture is in terms of delivery. The local intervention is absolutely getting an amongst that. At a local level, it is going to be really important that my officials do that, but we will make sure that we keep an eye on the bigger picture. Of course, we will use that data to inform future funding decisions, too, but we are quite rightly going to be held to account on this money, how it is spent and what difference it is making. I would expect that Ms Webber will do anyway. All parliamentarians to make sure that the Government is using that money in the most effective way possible, given the nature of the crisis that we are dealing with. Can I move on to questioning around sport and active living from Emma Harper? I am pleased to be asking about sport and active living. We know how getting out and getting a daily mile or getting a walk during the first lockdown was really important for people, including for their mental health. In the budget, there is a proposal that the investment is doubling to £100 million by the end of the Parliament for sport and active living, which is really good news. How will the additional funding for sport and active living be prioritised? The question is right. It is an important commitment. It has become even more important, given what we have been dealing with in the pandemic. We know how sport is not just good for physical health—of course, it is that—but it is also so good for mental health. It is really important that we live up to that commitment, which we intend to do. That £100 million is doubling our investment a year by the end of the Parliament. How will it be spent? It allows us to rebuild capacity in those areas in the sector following closures during the pandemic. We can be unaware of the impact that the pandemic has had on sports. That can be at a local grassroots level, such as the football club that she goes to on Saturday. It has been hit hard with the pandemic, but it does not have reserves to be able to reach into the right way through to the biggest clubs in the country. Of course, it is not just across one sport but right across the myriad of sports that we have and how they have been affected because of the lack of people coming through the turnstiles. Again, I do not pre-empt anything. The FFM will say this this afternoon, but clearly Omicron is giving us a great degree of concern in that respect, too. We will work closely with Sports Scotland and partners to understand how we can best increase that investment in physical activity and sport, while ensuring that we address the issues around inequality in some sports, frankly. I have done better at dealing with that issue around the inequality of access, but there are some sports and sporting bodies that perhaps have a little bit more work to do in that respect. Just a quick question on social prescribing. We have heard and we have had a previous report in the last session about the benefits of social prescribing that it is an investment, not a cost. We know that social prescribing is good for physical and mental health as well. I am interested in what needs to be done or what is being done to demonstrate that social prescribing is really good. How will that work help evidence that social prescribing could benefit from further investment? I am a great believer in social prescribing as is the Government. I can certainly look at what we are publishing in terms of evidence and evaluation around that. I will certainly take that one off-table and provide you with more information. Of course, our programme for government includes a commitment by 2026. Every single GP practice will have access to mental health and wellbeing service, and that will fund a thousand additional dedicated staff who can help to grow community mental health resilience and direct social prescribing. For me, that will make a massive difference in relation to the access to social prescribing. I know from the community link worker that I have in my constituency who does an incredible job reaching into third sector, reaching into other support organisations and helping with that social prescribing has made a big, big difference in the number of my constituents. I will look at what we are publishing or what we have published in terms of evaluation on that, and I will come back to the committee via the convener. However, on the general point that Ms Harper makes, I agree with it in this entirety. Can I bring in Ms Sandesh Gohani, who has a quick supplementary on that? Can Atkinson of the Scottish Sports Association give evidence to say that culture is free, why is sport not free? My question is, do you accept that the cost of facilities can be a major barrier to participation and, hoping that you do accept that, what measures can be put into place to address that? Dr Gohani is right. I do absolutely accept it. It is why I alluded to the fact in my previous answer that there are some sports that I think have done well in making their sport more accessible, but I think that there are other sports and sporting bodies that I have still got some work to do. We have, as we say in the 2022-23 budget, increased our funding for sport and to support Active Scotland's key outcomes in terms of encouraging physical activity, developing physical confidence from an early age, etc. We are working very closely with Sports Scotland to make sure that it supports clubs and communities to offer a range of opportunities for young people in particular to participate through community sports hubs. We will be making sure that we are doing as much as we possibly can to work through schools as well. We are doing what we can in and around, for example, when it comes to cycling. I take that as just one example, making that more accessible by providing bikes where we can to those who are not able to afford them and making sure that they are available in community hubs. I am happy to provide more detail where I can, but it is effective. I agree with the premise absolutely. I think that there are other areas where we probably need to fund. Cycling facilities fund is one example. There was another example. We worked well with the Robertson Trust, which I think many members will probably know, and its spirit of 2021 at Sports Scotland. We worked with it to deliver changing lives through sport and physical activity fund. That provided direct resource into the sporting and community sectors to address those wider access issues directly funded to 17 collaborative partnerships between sporting and non-sporting organisations to deliver sport and physical activity within their communities and, again, with a real focus on accessibility. The wider point that Dr Gohani makes is one that I am entirely in agreement with. I am sorry to curtail the sport question, but we only have 10 minutes left and we have two members who have not asked questions yet. I move on to talking about health inequalities and questions from Carol Mocken. Tackling inequality and poverty, I believe, is absolutely what we as MSPs are here to do, and it is across every portfolio. In our evidence sessions, we have heard from experts almost in every session that to tackle health inequalities, we have to tackle poverty. We have been advised that we need to be politically brave on that issue. My question is whether you are prepared to be politically brave on that issue. Can you give us some examples of what you believe we can do and some timeframes? That is such an important question that we need to know within what timeframes we are looking at measuring our outcomes. I agree entirely with Carol Mocken's assessment. I agree entirely with her plea to every decision maker and every policy maker that tackling poverty and inequality has to be the root of our mission here in Scotland, because it touches upon every portfolio in Government that is at a shadow of a doubt. I will rehearse everything that I said previously about the good work that we are doing with the DFM. The answer question requires you to be politically brave and politically bold, yes, absolutely. That is a challenge that we are up for. We have doubled the child payment once again. I have committed to doubling the child payment once again, which I know is something that Scottish Labour had been calling for and had welcomed. There are a number of initiatives. I should also know that we have committed to the family wellbeing fund again over the course of this Parliament, which is a significant investment designed to tackle child poverty. Some of those investments will take the course of the parliamentary term, and there is no getting away from that. If we were able to meet our child poverty targets sooner, we would absolutely do that. I think that Mocken is probably quite aware of the detail of those child poverty targets, and therefore I will not rehearse them in detail here. However, I just give her an absolute commitment that whether it is health education, whether it is transport housing or social justice, we are all absolutely at one on this drive towards reducing child poverty. As a person who is responsible for the largest share but quite a distance of the Scottish budget, I am not unaware of my responsibilities and that respect. I am interested in some of the evidence that has come from the Scottish Government to use the place-based community-led approach. I wonder if you could give some examples of where he feels that will make a difference. How did you say about the place-based community-led approach? That is very much in the papers. I wonder if you had some examples of where you felt that that would be something that we could use quickly for people. I suspect that Mocken is one of our belief in the importance of that place-based community-led approach. We have brought together a whole range of work that is focused on supporting local level action to improve health and wellbeing and reducing health inequalities with that very long-term preventative focus that we have already spoken on. We want to support health and social care services to work very much as part of wider systems to co-create wellbeing locally. That enables our health and social care providers to play their roles. They play their roles and institutions as part of that community wealth building. There are many good examples of that. One example of that would be the joint pilot programme that started earlier last year involving Linkup Gallatown, Cacody YNCA and NHS Fife, where local people provided training and placement opportunities in a local hospital. Many have gone on to secure employment. Parkhead, which I have already referenced, is another good example. That will be our single biggest investment in a health and social care centre. It will bring together community services that are currently located in almost 10 other sites, nine other sites. I spoke to one of the doctors involved in one of those sites, which is part of the deep-end project, which brings together 100 of those GP practices in the most deprived areas. She can see the value of the work that we are looking to do in that respect. I know that we are short for time, but I hope that we can make a commitment to come back on that issue. Just some final questions from David Torrance on linking the budget to outcomes. Thank you, convener, and good afternoon, cabinet secretary. The national performance framework has nine indicators and targets for health. How does that fit in with other performance frameworks, such as the local delivery plan, standards and integration of health and wellbeing outcomes? Can I ask what is the greater prominence in setting budgets and spending decisions? I think that I have the end of that question. The outcomes that are set out in the national performance framework are a consistent thread that runs throughout our work, and that inform our planning right across the board. In terms of prominence in influencing spending decisions that you asked for, it goes through everything that we think about every time we make a spending decision. We look at the outcomes of the national performance framework, some of the other frameworks that he mentioned as well, but the national performance framework really is our guiding framework for the whole of government. It is a consistent thread, as I say, that runs through all of our work and informs our planning across the board. All the information that is gathered in evidence in the national performance framework, has it ever led to definite specific changes in your budget plans? That is a good question. The national performance framework informs the budget. The impacts of commitments on outcomes are, of course, considered when we make commitments in this in terms of informing our budget. For example, increasing health and care spending will directly contribute to the health and wellbeing of the nation. We know that, and the First Minister often talks about how we cannot separate health and the economy, as people sometimes ask us to do. They are intrinsically linked. Increased workforce contributes to the economy, as does increased capital investment in health, which generates jobs and also moves us towards our net zero goals. Our commitments to fair work and pay contribute to our outcomes around poverty and health again as a role to play in each and every single one of them. Yes, absolutely. It sets our budget priorities and, as I said in my previous answer, is a consistent thread that runs throughout that entire consideration. That concludes our questions to the cabinet secretary on the budget. I want to thank Hamza Yousaf, the cabinet secretary and Richard McCallum for the time this morning. At our next meeting on 11 January, the committee will take evidence from stakeholders as part of our inquiry into health and wellbeing of children and young people. The committee will also undertake scrutiny on the draft mesh reimbursement scheme, provided by the Scottish Government in advance of stage 2 consideration of the Transvaginal Mesh Removal Cost Reimbursment Scotland bill at its last meeting on 14 December. Since that is our last meeting of 2021, I want to take the opportunity to send my good wishes and our committee's good wishes to all our stakeholders who have helped us over the year. That concludes the public part of our meeting.