 I welcome everybody to this, the 24th meeting of the public audit committee in 2023. The first item on our agenda is for members of the committee to consider whether or not to take agenda items 3, 4, 5, 6 and 7 in private. Are we all agreed? Yes, we are agreed. The main item on our agenda this morning is to take evidence on the Auditor General's report on the adult mental health, which was co-written along with the Accounts Commission. I am very pleased to welcome our witnesses this morning, Auditor General Stephen Boyle. Lee Johnson is here from Audit Scotland, where she is a senior manager. Eva Thompson-Tudo is an audit manager at Audit Scotland. I am pleased that we are joined by Christine Leicester from the Accounts Commission. We have got a large number of questions to ask this morning, but before we get on to those, Auditor General, can I ask you to make a short opening statement? Of course. Many thanks, good morning committee. I am pleased to bring the committee our joint performance audit report on adult mental health services in Scotland. Our report highlights that many people find accessing mental health services to be slow and a complicated process. The system is complex and fragmented, with multiple organisations involved in planning, funding and providing adult mental health. The availability of services also varies across Scotland. Further, some groups, such as people from ethnic minorities and those from rural areas, face additional barriers to accessing support. Progress in addressing mental health inequalities has been slow, but mental health services cannot address those issues alone. Our report is clear that they need to work more closely with other sectors such as housing, welfare and employability support to address and prevent the social detriments of poor mental health that affect around one in four people in Scotland each year. Over the past three years, people have also grappled with the adverse effects of the Covid-19 pandemic and the more recent cost of living crisis. Those effects have put an additional strain on the mental health of people in Scotland. More than £1 billion is spent on adult mental health each year, but our report highlights the challenges in assessing the impact of that spending due to limited financial workforce and operational data. The Scottish Government focuses on waiting times for psychological therapies to assess performance of adult mental health services. However, it does not report on the quality of services or the outcomes for people receiving mental health support. The Scottish Government recognises those limitations and is planning to publish new standards that aim to address some of those gaps. Although our report sets out many issues that need to be addressed, it also highlights positive developments. The distress brief intervention DBI programme has improved the care available for people experiencing distress. NHS 24 has established a 111 mental health hub during the pandemic and then expanded that to operate 24 hours a day. The Scottish Government has set ambitious mental health commitments for the end of this Parliament, including increasing mental health funding by 25 per cent, that 10 per cent of front-line spending will be on mental health and increasing mental health and wellbeing support in primary care settings. However, convener, those commitments are not on track to be achieved. The Scottish Government and COSLA has recently published a new joint mental health and wellbeing strategy. It recognises that a whole system approach is needed to effectively support mental health and wellbeing, but much more detail is now needed on how and when outcomes identified will be achieved. The Scottish Government plans to set out this detail in a delivery plan and workforce action plan expected this autumn. We will continue, of course, to monitor their progress against this and the wider recommendations in the report. Cymru, Lee, Eva and Christine myself will do our utmost to answer the committee's questions this morning. Thank you very much indeed for that introduction. Can I go back to the starting point of the audit and the question that you set yourself was how effectively are adult mental health services across Scotland being delivered? How would you summarise your answer to that critical question? It is fairly clear from our findings in the report that it is difficult to form an overall assessment. You will see from the report, convener, that the lack of effective data information to inform assessment of outcomes is really limited, much more so than we would expect. That there isn't clear information on finance, performance and outcomes effectively limits the assessment that can be made. We dug deeper during the course of the audit and colleagues can develop my response to bring in the views of mental health services and that led us drawing on their assessment and the assessment of a wide range of practitioners that what we have is a fragmented system. In Scotland, the delivery of mental health services is slow. As I mentioned in the introductory remarks, it is unequal in places. There is evidence in a number of exhibits that you don't get the same range of service or pace of services of mental health in Scotland depending on where you live or from which group in society you are part of. I will ask about those focus groups in a second. Paragraph 15 in the report sets out the scale of the challenge that we face. When it talks about what appears to be almost epidemic proportions, 22 per cent of the adult population may have a psychiatric disorder. You talk about the huge expansion in pressure and demand on services. The number of police incidents relating to mental health increased by 62 per cent. The Scottish Association for Mental Health reporting a 50 per cent increase in demand on its information services. The number of calls to NHS 24's 111 line in mental health hub increased by 436 per cent. Startling figures are placing huge pressure on the system. We may not have measured the outcomes but we know something about the scale of the demand at which there is. Do you want to tell us something a bit more about what qualitative information you got from the focus groups you met and what that told you about their experience? I'll bring Eve in to say a bit more and leave if she wishes to. To set out for the committee a rationale for bringing in focus groups and users and what they told us alongside triangulating that with the quality of evidence that exists. As I mentioned, we are managing expectations somewhat that that quality of evidence tends to be around psychological therapies as being the principal method with which the Scottish Government and its partners are measuring the effectiveness of mental health services. One of the things that we found with the focus groups was that it really brought to life some of the challenges that we'd been finding as part of our other audit work. It was really useful to get examples from real life about how the challenges that we've identified are affecting people trying to get support for their mental health. We spoke to a relatively small number of people, about 25 people across a few focus groups. We weren't able to make overarching judgments based on the evidence that we got from a small number of people but what it was really useful for was illustrating the points that we had found evidence for to bring that to life a bit. You'll see that we've put quotes throughout the report to illustrate those points a bit more fully. The only thing that I would add is that they just reinforced how slow and complicated it is to access services, express their often frustration with trying to get the right kind of help and support that they needed at the right time. That's a theme that I think will return to during the course of the morning, but I'm going to turn now to Colin Beattie who's got some questions to put to you. Colin. Thank you, convener. General, there's a couple of areas that I'd like to cover. One is a long-standing favourite data collection. I think you're now the third orator general whose time has repeatedly highlighted the issues about data collection right across the public sector. It's disappointing that we've still got this problem, particularly with mental health. It's a central theme in your report. We don't really know how much is being spent on adult mental health services. We don't know the outcomes, the qualities related to mental health services. We don't know what the demand is, even. Do you have a view on whether there's any areas that should be prioritised from what must be a long list of deficiencies to improve the data and information that's available? The resources, in any part of the public sector at the moment, are quite tight, so they need to be targeted where they're going to benefit the most. Do you have a view on that? Many thanks, Mr Beattie. First, I agree with you that the quality of data information has been a recurring theme from my predecessors and me and Audit Scotland's reporting for many years. It is disappointing that we are preparing another audit report that is again reporting that we don't have enough information, nor do decision makers have enough information to gauge the impact of considerable sums of public spending. We broadly know what's being spent on adult mental health services, so we are in the realms of £1.4 billion to £1.5 billion each year on spending, but the focus on assessing its impact is very narrow on psychological therapies and important, but only one element of adult mental health service provision. What we don't know is how effective that has been. Did it improve the outcomes for people accessing those services? I agree with the point that we are in a challenging fiscal environment. I'm keen to bring Christineine in, but he might want to say a bit more about where the Scottish Government and their partners go next with this. It is going to require a whole system effort. The point in terms of prioritisation is that there are signs of progress in that the Scottish Government and COSLA have set out their new strategy for the delivery of services and their intent that this is underpinned by a clear delivery plan. That is absolutely fundamental to assessing the impact of mental health spending and what outcomes have been achieved. Additional context for that is that you will know, of course, that the fiscal environment that Scotland is operating is very challenging. That will require difficult choices. That is alongside some of the changes that are taking place in the relationship between the Scottish Government and local government with the assertion of the Verity House agreement earlier this summer that intends to remove some of the fiscal constraints in terms of reporting on individual budget lines between local authorities and the Scottish Government. Part of that overall consideration, there has to be absolute clarity about what a cost of delivery plan can achieve. I'm keen to broaden that out to Christineine. I'm sure that she'll want to comment on that too. We know that there is a huge sum of money at the top, but we really cannot recognise at the bottom how it is divvied up and gets to the service end. It is very complicated at that service end, so in terms of the work that the Accounts Commission does through local authorities, integration joint boards and then also the third sector and health and social care partnerships are all delivering those services. We actually know the moneys that are then spent individually and how they are impacting over a period of time, because those are commission services quite often in the third sector. It's complicated, it takes a long time to get mentally ill to the point that you need to use those services and then it takes a long time to get better again. That being able to deliver services over a bigger timescale than 12 or 18 months is hugely important at that point. I hope that that helps in some way. You did touch on something interesting there of the £1.4 billion or so. What proportion of that goes to the third sector? I think that Eva is just looking for the figure on that in terms of the allocation of resources. It will be really varied, Mr Beattie, so that across at a high level £1.2 billion is allocated to NHS boards. We have another £200 million to local authorities. Then a similar amount within the Scottish Government mental health directorate. What we have seen particularly over the course of the pandemic is a significant increase in the mental health directorate spend. Part of that were Covid-related funds. I think that Christine Beattie says that there are a number of funds that operate to provide mental health services, different types of interventions that are required. Across the piece, we don't yet have the data or the evaluation of the spending to say did that make an impact, whether it was in the third sector, NHS boards or local authorities. It is a complex system, but not enough evaluation of whether it has made a difference. If we have more detail on the specifics of the third sector. I think that it is quite a difficult question to answer. Has Stephen set out the way that the funding is distributed, some of it is spent centrally by the Scottish Government, some of it is allocated to NHS boards, councils also spend a proportion of money on mental health as well. Within those, for instance, NHS boards will commission services through the third sector to deliver services. We don't have the detail about how much is spent on commission services for instance right now. There are some pots of money that go to the third sector that we are aware of. For instance, part of the century spent amount by the Scottish Government mental health directorate has gone on the recovery and renewal funding. Part of that was community mental health and wellbeing fund that we talked about in the report in paragraph 71. Some of that will have gone to the third sector and distributed by third sector interfaces. We touch on that in the report. It is very difficult to give an overall figure about how much mental health spending as a whole goes to the third sector. Obviously my concern about trying to evaluate the outcomes and so on through the third sector are that they are very difficult to get information from in terms of auditing to validate these outcomes. I know that the Auditor General is limited in what he can do there. I think that the key thing here is that if we don't know what the outcomes are across the board, then we don't know if the money is being spent in the right place and that's the key takeaway from that. Yes, we agree. What we have is considerable sums of public spending. We know where it's been allocated to but we don't know whether they have made a difference, as intended. The third sector plays an enormously important role in the provision of adult mental health services, prevention and support across a range of different factors and geographies. One of the factors that it tells us is that it is not unique to adult mental health services is that their funding cycle is almost always on a regular basis. There is a challenge for them to recruit, retain people who can provide skilled services when there is that uncertainty. If we are making a step change, which I hope we do, in the provision of adult mental health services, the accountability, the funding and the outcomes, that needs to be given careful thought to about giving practitioners in the third sector certainty about how they can apply their work over a longer space of time. The difficulty with that is that the Scottish Government is only funding on an annual basis, so there is some uncertainty as to what the figures will be. I think that that is fair, but perhaps up to a point, the Scottish Government and local authorities will generally know from year to year what their baseline is. They will have certainty that they will get a sum of money generally around the amount that they had last year. That is much longer for that certainty to be given to the third sector. I think that there is something to be done in that arena, too. Let me move on to another area. The Scottish Government's emergency budget review. What impact has that made on the delivery of mental health and wellbeing in primary care services? I will bring Eva in to set out for the committee in a bit more detail. You are referring to Paragal 32 and the circumstances of the Scottish Government's review of its spending plans during 2022. When it identified—I think that some Audit Scotland reporting around about it at the same time—that it had challenges to deliver a balanced fiscal position, which you are referred to, they are required to do each year. Part of that analysis was to look at different budget lines and to stop spending, where it was identified that either the budget was not needed or that it was going to be underspent. I will ask Eva to say a bit more about some of the numbers and what judgments we have been able to make. We have already talked about some of the limited availability of data to make some of those assessments. The EBR cut funding for mental health services by about £38 million last year and primary care funding by £65 million. The impact of that was that local areas who were trying to develop these primary care mental health and wellbeing services by 2026 were unable to recruit some of the positions that they were hoping to in that year. That is one of the main reasons that we have made the judgment that that commitment to establish these primary care mental health and wellbeing services by 2026 is currently not on track, because that progress has been delayed. Your report recommended that the Government should publish a cost-to-delivery plan setting out the funding and workforce needed to achieve its aim of a sustainable and effective mental health and wellbeing in primary care services. I think that the target date for that was 2026. What confidence do you have that that recommendation is progressing? Are they actually actively doing this? We know that work is under way to do so and there are planned publications over the course of the autumn of this year. This has to be a very comprehensive, clear, transparent document that sets out how funding, performance and workforce will be delivered across a range of different service providers. They have to get it right. It is the blunt assessment that I would make. There have been mental health strategies before. We touched on that in the report as well, together with interim progress reports that have not always given the level of clarity or accountability on how public spending on mental health services has performed. We hope that the judgment and the recommendation that the council commissioner and I have made in this report is acted upon because it is absolutely essential that, not just for accountability purposes but for building on a number of conversations that the committee has had over many years, that the most effective public spending will be upstream, preventative spending that will be less costly and more effective. If we are continuing to service a system that is secondary, acute or reacting to a crisis, it will be more expensive. We will have the circumstances that we lay out in the report where there are real workforce challenges in different parts of mental health provision and in different pockets of Scotland. We hope that it is. For the committee's assurance, we will continue to track and monitor the progress that is made with a costed delivery plan. On another aspect, on paragraph 37, you highlighted some of the issues that you spoke about in your opening statement, which are the inequalities. There are certainly many inequalities in mental health. If there is a clear link between mental health inequality and inequalities in society, you will be able to see that. Can you give us a bit more information about what your audit work found in that area? It does encompass a broad number of factors. You are absolutely right. I am sure that Eva and Christine will want to say a word or two about that. At a headline level, we found that there are stark inequalities in the provision of mental health services, not just the rural disparities that exist in the provision of service. We also found—I am sure that you will come as no surprise to the committee—that if you are from a deprived area of Scotland, your access is not equivalent and your outcomes are not the equivalent of some of the more affluent parts of the country. In our report, we also note that, for people from ethnic minority backgrounds, there are language barriers to accessing services, and some of that has also been impacted by the provision of either face-to-face or remote service provision. Where it has led us to Mr Beattie is really an assessment of this large complex and at times fragmented system. I mentioned in an opening statement that adult mental health service providers themselves cannot resolve this. This is a multi-faceted complex area of public service. It is going to require a clear plan prioritisation, governance accountability, all of those things from across local authorities, health service, Scottish Government, third sector and housing providers, so that we are able to have a much more person-centred, preventative model of mental health services in Scotland. It also gets the information right so that a system as complex as this will inevitably continue to need tweaks and evaluation. However, if we do not have the information to make that assessment in the first place, I fear that what we continue to do is just to keep spending year after year without that rounded assessment of what difference it is making. Paragraph 39 says that the Scottish Government recognises the importance of addressing inequalities in mental health, but you state also that the impact of its commitments are not always clear. Perhaps in the response you could include how the Scottish Government is going to address these concerns. That is correct. I think that I have noted that the Government has recognised and is making some progress. What we want to see is that progress built upon with a clear, costed delivery plan that sets out how they intend to deliver upon their commitments. I will pass it to the colleagues in a second, but maybe before I do, just to mention one of the key drivers that the Government intends to enact change in mental health service provision through a more upstream preventative approach is investment in primary care services. The intention is that mental health workers will be based in all GP practices in Scotland by 2026. What we have identified in the report through the work that we have done is that that is at risk without the clear pathway through spending workforce performance information to get to that point. I am sure that the committee will want to come on and talk further about workforce challenges, but it is an essential component of that. You are correct, Mr Beattie, that the Government is recognising and has plans. My caution is that successive Governments have had plans, but what is not followed through is the detailed costed plan from how to get from a strategy to implementation that can be evaluated upon. I think that having the national plan is fantastic and all very well and very much needed, as we have said. If Scotland is a very diverse place, so if you live where I live in rural Murray, the mental health problems that we have there are very different to the mental health problems that you might see in Glasgow or Dundee or somewhere like that. The delivery of the services has to be done at a local level. I think that we go back to what we were talking about, how the services are commissioned in the third sector, because they are very much tailored to the individual requirements of that particular locality. The problem is that the route through which the money has to go to get there is complicated. Eva mentioned that the money that goes to the NHS is then used to commission services. Those services are mainly commissioned at local level through integration giant boards through their strategic commissioning plans and then implemented from then on. They are very diverse and very different. If you go back to inequality, inequalities are different. Rural poverty at cost of living where I live is very different. It is fuel poverty and things like that, very different to the sort of poverty that you might see in inner cities. When it all comes together, when you have the intersectionality of poverty, ethnic minority, physical disability along with your mental disability, it all comes together very often. Those people are very much in crisis, but they are probably known to one or all of the organisations that are tasked by the Government to look after them. By that, I mean housing, GP services, et cetera. You can see how complicated it becomes at that level. Community planning partnerships have a role in that, I feel. In your state. Thank you. I guess just a couple of things to mention. In 2020, the Scottish Government published the mental health transition and recovery plan in response to the impact of the pandemic on mental health. That was quite clear about its recognition of inequalities as being a significant issue. It set out actions to tackle some of those inequalities relating to employment, women and girls' mental health and socioeconomic inequalities. The plan did not outline timescales for all of the actions and has not carried out review of progress of that plan. One other thing to mention is that the new mental health and wellbeing strategy that was published earlier this year also had quite a significant focus on addressing inequalities. However, as the Auditor General mentioned earlier in his response, there is very little detail in that strategy about how exactly it is going to tackle that. That is why the Scottish Government is intending to publish a delivery plan for that mental health and wellbeing strategy this autumn. That, we are hoping, will include some of the detail about how exactly it is going to tackle some of those inequalities. I am going to bring Graham Simpson in a minute, but can I take you back to the emergency budget review just to fully understand what you are saying? Auditor General, you said that the exercise was about identifying underspends and rationing the public finances according to that. However, when Eva Thomas Tudow spoke about it, she said that, as I interpret what you said, that exercise has knocked off track the targeted support, for example, for GPs by 2026. Was that going to be underspent, and that was the reason why this £38 million cut was made, or has the £38 million cut caused the assessment that you have made that it is not going to be on track? It is potentially both those lines, convener. I recall that the Finance and Public Administration Committee took evidence from the former Deputy First Minister on some of the emergency budget decisions. I would need to refer back to the official report just to check the precise explanations. What we have seen from our work and our own assessment is that the emergency budget review was, on an overarching level, designed to look at areas of spend that the Government assessed weren't progressing either through not having the demand, as intended, or that it needed to de-prioritise for other areas of spend in order to deliver financial balance. I might need to come back to the committee on writing just on the precision of that. Is it possible that it was de-prioritised? I think that it is possible, but I would need to check. Graham Simpson. Thanks a lot, convener. You've spelled out quite a number of quite stark statistics. The first one that you use in your key facts is about one in four people experiencing mental health problems in any given year. Given that we've already discussed the difficulty of getting data, how do we know that? You're right, Mr Simpson. There is a potential, and a very real potential, that the statistics that are quoted both in terms of the scale of mental health challenges as one in four. The report also notes that the Mental Health Foundation 2019 estimated that the cost of mental health service of mental ill health was approaching £9 billion per year to the Scottish economy. However, as you are alluding to, the fact that there isn't sufficient robust reliable data means that these are estimates and the possibility that there is an unmet need in society for some services that goes alongside the numbers that are reported. Perhaps that illustrates the scale of challenges exacerbated by Covid-19. We can't really say with any certainty that one in four people in any given year suffer mental health problems, because that would mean that in this room, maybe three or four people suffer mental health problems this year. I just don't know how we could possibly know that. Eva, can you set out for the committee some of the sources that we drew on to arrive at that? That particular figure comes from the Scottish household survey that is carried out each year, and that one estimated that about one in four people in any given year would experience a mental health problem. It's based on survey responses. What sort of question would you be asking to arrive at that? I'd have to check the specific wording on that one, but that's also where the figure for where we've estimated how many people may have a psychiatric disorder. That's where that's come from as well. I can find out the specific wording for you and perhaps we can get back to you on that, but it's essentially based on survey response. Perhaps just to lend some weight to that, Mr Simpson. We draw on a range of sources for our report, recognising again that the quality of data isn't what we would like it to be, not just for our purposes, but really for those that are making the decisions on public spending and service provision. One of the data gaps that exists and is explored by the committee in previous sessions is on primary care services, so GP consultations, for example. There isn't clear enough data there, but we draw on, again, further information that's nothing from England that notes that around 40 per cent of GP consultations in England are in respect of mental health concerns. Those two statistics are not the same thing, but it illustrates the scale of mental health in Scotland sufficiently. I was going to ask about GP, so do we have an equivalent figure for Scotland, or do we just not know? Again, we do not have a precise figure that can reliably say what GP engagement was in terms of mental ill health. Why do we not have that? Why is that not recorded? Lee might want to say a bit more about this, given our review and commentary. Again, as Mr Beattie mentioned, it's a success of reporting that we've done on the NHS that we do not have in Scotland. Despite having a very comprehensive statistical recording arrangement through NHS National Services Scotland, Information Services Division, where we are lacking is in primary care information. Lee, can you say a bit more, I'm sure? I guess just to agree with the Auditor General, we have commented on a number of occasions about the lack of data in primary care. Public Health Scotland is working on it. It is trying to improve that situation, but the data that is available right now is experimental and it is trying to develop it. It is more robust and reliable, but whether or not that will include how many appointments are to do with mental health remains to be seen. We have commented on it on several occasions about the lack of insight and data into what is going on in general practice. It's pretty fundamental. It comes out very strongly in the report. This lack of data, a confused system, it's slow and complicated, people don't know where to go. You would think that, of course, mental health covers a wide range of things, but for many people the first port of call could be the GP. A GP is set up to deal with it. It doesn't sound from your report that they are. I'll bring to the committee's attention exhibit 1 in the report. We set out a bit to the patient journey in terms of people who are experiencing mental ill health. From prevention and self-help to primary care settings, if that is not helped or resolved or to manage conditions on to secondary care and specialist tertiary care, I would absolutely recognise, Mr Simpson, that the Scottish Government in its strategy has set out that increasing the provision of mental health services in primary care settings is fundamental to help tackle the problem. And their ambition to do so by 2026 is central to that. What we have noted in our report is that that is at risk without provision of a clear, costed delivery plan to get to that point, given the variables. And also the starting point, as the report also notes, not just the lack of high-quality information, but also, if I may say again, some of the workforce challenges that are present to get to a comprehensive provision across the country in three years' time. You've mentioned a few times now this ambition that every GP practice will have somebody there who is a specialist in mental health. By 2026, every GP practice will have that. Where are we now? I think that one thing to note, based on the previous response as well, is that there isn't good quality primary care data out there, but an estimated 41 per cent of GP appointments relate to mental health. It's potentially significant and that's based on, again, survey data, one-off pieces of work. I think that the Royal College of GPs has also told us that they need more support to help tackle mental health. In terms of where they are now, a couple of surveys have taken place to find out how the proportion of GP practices in Scotland that have access to mental health workers. In the last survey, it was estimated that 17 per cent of GP practices across Scotland reported having no access to mental health workers. The year before, 45 per cent of GP practices reported having full access. The difficulty with the most recent data is that it only counts any access or tools that can range from minimal access to full access. It's very difficult to say how many GP practices are in a position where they've got sufficient mental health workers. What years are you referring to? The one where 45 per cent of GP practices have full access, that was 2022. In 2023, we don't have that level of detail, so all we know is that 17 per cent had no access. Last year, 45 per cent of GP practices had some access, but we want to get to every practice having full access by 2026, so there's an awful long way to go. I just want to ask about one more area if I can. In your report, it's on page 13, paragraph 16, which covers two pages. You refer to the number of police incidents relating to mental health. I'm sure that all MSPs will be speaking to their local police every time they speak to them. The majority of their work now is taken up with mental health cases. I've heard figures ranging from 60 per cent to 80 per cent. Quite stark dealing with people with mental health and taking police away from other duties. That's not the police's fault and it's not the people with mental health issues. It's not their fault either, but it is a problem. Did you speak to the police about this? It's a serious issue out there. Eva, can you say a bit more about the engagement that we had during the course of the audit? I think that the point that I would maybe just develop, Mr Simpson, is that we're reporting that there's been a 62 per cent increase in police mental health response incidents over the past seven years. Clearly a hugely significant increase in their focus and attention, but it's also relevant as it relates to the financial position of the police, the prioritisation that that organisation will have to make as it too looks to deliver a changing service and meets its own budget priorities. We do have a range of sources and evidence as we're setting out, but Eva, can you say a bit more about our wider engagement? We did speak to the police as part of our audit work early on in the audit. We haven't covered in detail the role of the police because the HMICS are publishing a report on policing mental health shortly. We spoke to them about their work and we've left it to them to publish that piece of work. HMICS, the Inspectorate for Constabulary Scotland, I think. I'll leave it there, convener. Thank you very much indeed. I'm going to go straight on now to Willie Coffey, who's got a series of questions to put to you. Willie Coffey, thank you very much again, convener, and good morning to the Auditor General and colleagues. I've had a range of questions, but I'd like to stick with the one on the GP issue that Graham Simpson was asking about. We've got a comment in the report from the Royal College of GPs saying that the GPs need more support. It's a starker act to address mental health needs of patients. Some comment in the focus group, Eva, was saying that people seem to prefer the support they get from the GP rather than psychiatric services. There's another bit in the report, something else, that talks about access to mental health officers with the funding being there but not being taken up. There's a whole range of issues swirling around here. I wonder if you could just say a bit more about what your understanding of this particular issue is and what are the GPs actually asking for. Good morning, Mr Coffey. I'm happy to start, I'm sure, Eva. I want to say a bit more about particularly the views of focus group participants and that of the Royal College. I think that it's set out in even our previous response. So we have just short of 50 per cent of GPs currently having mental health provision. There's a long way to go over the course of the next three years to get to a full provision across a primary care setting. As things currently stand, GPs are still providing that service but without the additional skills and capacity within their practices to do so. Inevitably that brings real pressure upon primary care practitioners to deliver the service. That probably speaks to the views of the Royal College about the challenges that their members are currently facing. I'm sure that Eva will want to develop that. There are different views from service users about the best experience that they can get. Some will refer to mental health officers, others note the quality of service that they receive from the GP, and some note that this is just as competent from the multidisciplinary team that they can get over the course. I really want to illustrate in today's report that there's a long way to go for the Government to deliver upon its ambition to have that preventative primary care-based mental health service that is expected to deliver similar results. We draw on case studies from elsewhere in the world where that has been targeted successfully. I'll stop for a moment and bring Eva in to say some further. In terms of the views from the focus groups, as the Auditor General said, it was mixed. The point that came through strongly and the quote that you've referred to, was essentially illustrating the point that GPs play a significant role in people's day-to-day health. If someone needs a psychiatrist, they see the psychiatrist every so often, but that's not enough to keep them well in-between those appointments, for instance. They get more frequent care from their GP and from community support groups and that kind of thing. I think that's the direction of travel that we've seen a demand for, where there's a range of support available for people and they're not just relying on those kind of specialists for all of their support. Okay, that's really helpful. It's a very difficult area to put down here. I'm just wondering if what we're actually saying is that the GPs themselves need to be more skilled to be able to deal with, or do they need access to that skill to be brought into their practices? A bit more closely, is that what we're saying? I don't know if we're saying it with quite that precision. I'm sure that that might be a view that might be better expressed by GPs and the representatives themselves. What we've assessed is that the expansion of mental health services in primary care, yes, will involve GPs, but also that multidisciplinary team of service providers, whether it's psychologist, mental health nurses, mental health officers, so that there will be a tailored approach to individual requirements. Thank you for that. I wonder before I move on to a couple of these other queries that I have. Do you know if there's a diagnostic pathway for adults with ADHD deliberately under this because of a number of constituency casework that is coming to me, but there appears to be none? I wonder if any colleagues could help us with that query, and is there any work going on to try to address that? Maybe, Eva. It wasn't a specific focus of the report in terms of the provision. We do refer to, in the report, the extent of prescribing drug usage to treat certain conditions, Mr Coffey, our ability to draw conclusions on specific mental health illnesses. We deliberately sought to make it an overall assessment of provision, but Eva may be able to help with that further. I was essentially going to make that point that we didn't look at specific conditions as part of our audit work, but it has come up that people with ADHD are struggling to get the assessments and things that they need. Particularly for adults, because there is a process for younger people, but when it comes to the adult population, there appears to be no pathway to diagnosis. Or, Christine, is there anything that you are familiar with that might help? No, what I would say is that we made, as Eva said, a deliberate decision at the start of scoping this audit that we weren't going to make it diagnostic specific. We were just going to cover the whole range, but I think that it's worth, as well as thinking about those suffering from ADHD, dementia and Alzheimer's. That takes up a huge amount of service provision, and quite often it's the same services that are providing to other elements of the mental health care in a community setting. Your point is well made about specific conditions, but I would also like to say that adult dementia takes up a huge amount, and they are by and large the same services that are being used across the piece, primary care, support groups, peer groups, third sector, that sort of. Thank you very much for that. Steven, your report tells us that access to a range of mental health services in depth to obviously during Covid in this by and large going back to those pre-pandemic levels, but not for psychiatry services, it seems to be saying there. Do you have any views on why that would be the case, why the number of psychiatry appointments has decreased from other services have kind of recovered to their pre-pandemic levels? Mr Kofi, you're right. You're referring to exhibit 2 in the report where we set out the change in activity across a range of different mental health specialisms between October, December 2017 through to the end of last year. I think that, as the committee would expect, and you've seen from previous reports on NHS activity, there was a considerable drop and then largely consistent what we reported in previous NHS overview reports on how that activity recovered across a range of specialisms. On specifics with psychiatry, again, colleagues may want to say a bit further about this, but that's been one of the key challenges in terms of recruitment and retention of specialisms. We know in the report, Mr Kofi, that what we've seen is that because there are so few specialists in this area that some NHS boards are recruiting from one another to make this provision, it's perhaps a longer term review that is required about, as part of the workforce considerations, how are people coming into that specialism, how are they retained and that is part of that costed workforce financial plan that's needed across the piece to ensure that consistency of the provision across specialisms. Again, Eva might want to say a bit further. Psychiatry is one of the areas where the availability of information is very limited. The number of appointments are published, but there's no information about number of referrals, waiting times, how long people are waiting etc. It's very difficult to say why appointments are going down. It's very likely that the challenges with recruitment and retention that the Auditor General has set out is one of the reasons, but without further information it's very difficult to come to a judgment about. We don't know whether, for instance, the number of people being referred has decreased or increased, but the Royal College of Psychiatrists has told us that demand is high. They've done some specific pieces of work in Glasgow, so we've not been able to see that data, but they are telling us that demand is high. Okay, thank you for that. Turning to, there's a really interesting table in here about access to services through digital means, even as usual, highlights. Quite a difference right across Scotland in terms of whether consultations are digital or face-to-face, and so on, and I was taken by the Ayrshire and Arran figure, being the highest in Scotland for face-to-face. Can you offer a few ideas on what's going on there? Why is it so varied across Scotland? Is there any observed impact on the difference between face-to-face versus digital? Why is the harder part to answer, Mr Coffey? What we've set out at Exhibit 3 is the psychological therapy variation that takes place across Scotland. You're right to highlight Ayrshire and Arran as the highest for face-to-face at 86 per cent of recorded appointments. On the other end of the screen, we have NHS Orkney with 94 per cent of virtual appointments. The most important thing about this consistent with Government strategy is that patients have choice about how they receive psychological therapies. Perhaps some of the other focus group commentary, Mr Coffey, is that, again, there wasn't a universal picture from people we spoke to. For some, they said that virtual appointment was what they wanted. It increased the speed with which they were able to access services, but others are saying that it's not right for them. They get much more benefit. The primary path has to be that patient choice is seen in terms of the access to services that they want. Why is what is, again, the more limited component of the information that's available to us? Indeed, it may be an area that the committee should decide to explore further with wish to look at. Do you see that continuing that model of mixed hybrid face-to-face just continuing for the foreseeable? Do you see that becoming the norm, that there's a choice available to be able to choose whether it's face-to-face or digital? I mean, it's not really a choice. It's a necessity to do a lot of digital access by the sounds of it. I'll say a wee bit further. Again, Christine and Eva might want to say further, just to highlight for the committee that we currently have an audit under way on digital exclusion. Given the pace of change that is existing on the provision of public services, whether it's accessing mental health services or other parts of public service, as we move to a digital service provision, that goes at the right pace and respects different choices and different benefits that come from both digital and a face-to-face model, Mr Coffey. We'll be important to the committee to gather myself and the Accounts Commission in early 2024 on that. I'll stop on that for a moment. Eva and Christine may wish to say further. Do you want to give that? Yeah, I think it's access to digital that may account for some things. People don't have the means, they don't have broadband, they don't have the infrastructure around them to be able to do that. They may not be able to do that very easily because of a language difficulty or something like that, so maybe face-to-face is better for them in that instance. Digital exclusion is a big issue and, as Steven said, we're doing work on that now. Around whether it's equal across the piece, it definitely isn't, even on a geographical basis. Never mind the other inequalities that we've mentioned. I would say that it's choice is first, but if you're in crisis you want what's quickest and sometimes it might be quicker for the digital intervention than it is for the face-to-face intervention, but I don't have any evidence to support that. I'll just look at the chart again there, Steven and Christine. The Orney-Shetland picture is almost the opposite of one another in terms of digital or face-to-face. It seems to be almost a polar opposite. Both in the Western Isles, there's incredibly high in terms of digital telephone video access for all on face-to-face. There's quite even quite differences within the rural setting in the islands there. It's very different picture. Anyway, I'll leave that query there for another day. Just lastly for me, convener, another point in your report, Steven, the paragraph 29, you talk about the Government issuing its planning guidance to the IJBs, integrated joint boards and so on and so forth. It's part of their improvement in mental health and wellbeing care services, but we were expecting the report, I think, in, well, April 22. It's not appeared yet, is it? Could you offer some more comments on that and when we might expect it? Yeah, you're right, Mr Clawby. I think I might as quickly pass on to Christine, given the Accounts Commission's role in overseeing the work of IJBs, but we're absolutely, you know, so I think, as we've touched on a number of times already, that guidance and strategies are important, but actually giving clear guidance on what's to be delivered and how it's to be delivered, evaluated, the information that's to be collected is the underpinning that is needed to deliver IJBs and other service providers to take that next step to effectively implement the strategy ambitions. Christie? Yeah, thanks. IJBs have the job of commissioning the services that are then delivered by the health and social care partnerships, who are then staffed by councils, third sector and the NHS, depending on which strand they come from. So you see the difficulty there, but I think IJBs definitely have a role in everything together, because the money goes into that pot and then they can decide in their locality how it's best spent, so whether it's via housing, whether it's transitions, because that's the other thing, child and adolescent mental health become adults eventually, how they manage those services. So IJBs definitely have a role in that, but the delivery of it is through the workforce of the local authority and the NHS and we have issues there which we've alluded to about workforce and workforce planning in that area. Do we have a date for publication of that guidance? I don't have a date. We don't know when that's due to come out, but like you mentioned, it was due out last year as part of the commitment to establish those primary care mental health and wellbeing services by 2026. That was what the guidance was for. It was to measure outcomes from those services. We would like to see that either as a separate document as originally planned or built into another kind of delivery plan that they're planning at the moment. We've recommended in that paragraph that that should be published as soon as possible. Can I just say something about measuring outcomes? Because it's really important that the outcomes are the individual's outcomes that the service feels they can deliver. I think that that's really crucial in mental health above everything else because it might be something quite simple in the case of anxiety in terms of dealing with that. It's that individual's outcomes so how you measure that is incredibly difficult and how you audit it. We're still trying to get to grips with we are doing some work between us and with Public Health Scotland as well to try and get a bit more of a handle on real-life outcomes as opposed to audited financial outcomes etc. For years we've never asked people how they feel about the treatment and services that they've got. We've never asked. There's a stigma attached to speaking about mental health as well isn't it? You said earlier about one in four that all that means may be in this room but it might be true in this room but there's a stigma attached to talking about it. It's not like having a broken leg or a sore hip. I think again that we have to recognise that and be open about it. To say one word on it, Mr Coffey, we risk over complicating these things. Did it make a difference to the person that received the service and we can say yes it did, great, we'll continue doing that or you take an evaluation approach and say what different things can we do. These are the next steps that we've talked about and one other thing is that inevitably this is going to require work across partners Scottish Government councils, health boards and so on that in itself is easy to sign up to but having a clear shared plan at shared accountability is also vital. Thank you very much. I have total evidence to this. Self-directed support, which is a welfare payment, that in Murray when I was involved we had a client who used their self-directed support payment to buy a fish tank, to put fish in and that solved their anxiety problem. It gave them something to get up for in the morning and that was their outcome, it worked for them and in terms of best use of public funds it was great use of public funds because it lasted for as long as the fish and then he went and got more fish. Genuinely that's the sort of thing that makes a difference to people's lives that they can get up in the morning and they've got something to look forward to and something to relax about and that's the sort of level of outcomes we should really be trying to look at. That's a lovely story to share with the committee. Thank you for that. Thank you everybody for your responses to those questions. Back to you, convener. Thank you very much indeed. I'm afraid I'm going to bring us back to the institutional architecture and all that because one of the things that I take from the report is that you do seem to bring out a view about where are the IJBs in all of this. So a lot of attention is on the health boards outcomes and the local authorities outcomes but the IJBs are supposed to straddle that and pull that together and integrate that, literally. Do you want to say a word or two about what conclusions you drew from the work you did about the role of the IJBs? I'll be brief, convener, and Christine I'm sure will say more than me. But what is clear in the report is that the accountability seems mismatched. So the funding, while commissioned through to the IJBs, accountability still seems to rest with the health boards from the Scottish Government's funding direction. That needs to be resolved if we are to have one of those effective pillars of how public spending can be delivered more effectively. Christine. Thank you. IJBs don't get funded directly. Their funding comes from the council, the local authorities and from the NHS boards. So it has to trickle through that and then through into their commissioned services. So therein is another difficult problem because they have to work in commissioning those services on an annual budget but ahead three, five years. You know, when we're asking councils and IJBs when we're auditing them, we're asking them for medium and long-term financial planning. So they have to be doing that with an annual dollop of money. When it goes into the IJB, it's supposed to be used in a way that's specific for that locale. So where I live it would be very different. Are they held accountable? I'm not sure about that. I think it's very difficult. It's complicated. It's not well understood. I've been at committees here before in this place. I struggle to see that there's been any change in the understanding of what an IJB can do and what it's able to do. So there's no doubt about it. The IJBs and whatever follow them in the next iteration of what's coming, that needs to be very keenly thought of because it can't be done as it's being done now in the future. I mean, I think we were described in Parliament just last week as being quite a mixed bag. So I don't know whether you've discerned from the auditing work you've done that in some areas the IJBs are accountable, are working well whereas in others they aren't. You don't need to name them, but do you get that sense that there are different performances in different parts of the country? I think we do, but they have different challenges and they work within different communities. In some smaller local rural communities, communities are much more focused on coming together and working together to help with the challenges that are in that specific location. I'm thinking about remote and rural areas in particular. Actually, inner city areas are the same. You look at Dundee in some of the community work that's being done there. So they are very different, but by their very nature I think there's 31 of them. You know, they can't help but be different and it's the challenge. But there is a challenge around workforce planning and leadership as well. How do you find 31 leaders to deal with that environment on a day-in, day-out basis? It's very difficult. Maybe, maybe not. Ultimately, if we're creating these institutions and Parliament is legislating to set up a way of delivering services, then we would expect that there would be leadership necessary to drive that forward. As a Public Audit Committee, I guess that's what we would expect as well. Our focus for our strategy is the Accounts Commission. We will be looking very much at leadership going forward and whether or not we have the available workforce and the way of recognising it. I'm conscious of the time and we've still got some important areas to cover. Can I just very quickly, as we're on local government, about the Verity House agreement? Auditor General, I'll start with you. Just to give your assessment of whether you think that will make a difference in the delivery of mental health services. I'm probably not in a position to reach a view on it yet, convener. We've seen as a statement of intent from the Scottish Government and COSLA in terms of funding, accountability, talk of a fiscal framework. For what I understand, there is much work happening to do before that's set out more clearly over the course of the next few months about how that will operate in practice. I look forward to seeing further detail. If it is to act as a template for more accountability for where decisions are taking, that can be a helpful thing. As I'm linking back to today's report, we've said that it is quite a cluttered, unclear, complex governance accountability landscape. If that helps to bring clarity to how services will be delivered and associated accountability, we'd welcome that. I look forward to seeing more detail. To Christine Lester, is the Accounts Commission going to be monitoring the Verity House agreement and its outcomes? I don't really think that that's our role. We're looking very carefully at it. We're speaking to local authorities about it. The prospect of a fiscal framework would be very welcome in terms of what we've already discussed about commissioning services for the longer term and being able to sustain them over a greater than a 12-month period. That's helpful. Can I just turn a little bit again to progress towards improving mental health services? Can you tell us a bit more about the support that the Scottish Government has been providing to NHS boards to help them to meet their psychological therapies waiting-time targets, which is highlighted in the report? Yes, I can. I'm going to bring Lee in to say a bit more detail in this. In overall terms, we set out a paragraph 45 in which we believe that there's a 90 per cent target to deliver psychological therapy waiting times. We're going to develop that in the exhibit that, to date, none of the NHS board areas in Scotland are meeting that target to varying degrees. The support provided, though, is set out in paragraph 47. There has been provided tailored support to some NHS boards. We note in NHS Grampian, for example, back to the point that we discussed with Mr Coffey, that the availability of really specialist individuals can impact upon the performance of the health board in the round. Again, it comes back to workforce plans, longer-term plans in the future, but also actions in the short term. Pass to Lee if anything further she wishes to share with the committee. I don't have much to add, just to say that that support was tailored to the different areas that received it, so it would be very much based on their local circumstances and their local needs, but focused on trying to reduce the waits for people who have been waiting the longest. In our case study in terms of NHS Grampian, we give an outline. Some of their improvements were delayed because they were waiting for a long time for a director of psychology to help to make improvements there. They were also facing some challenges around the quality of the data that was supporting their psychological therapies output. They have since tried to improve that by implementing a new system that will gather more robust data that will give them better insight into what is going on. You mentioned Grampian, but also highlighted in the report is Tayside. Tayside has been the subject of not just local but national interest because of some of the tragic cases of people who have completed suicide, for example. In the case study, you characterise things as being in a state of making good progress. I think that when the STRANG report came out, subsequent to that, there was an assurance board, oversight and assurance group put together to ensure that the health board was implementing the recommendations of the STRANG review. I think that there were 51 recommendations, but as I read that oversight and assurance group report when it came out in January, echoing some of the points that STRANG had made, there was an over-reporting of progress by NHS Tayside in this area of service. In 17 out of the 51 recommendations, they were taking issue with the health board's view of how well it was doing, basically saying that you are not making the progress that you are stating that you are making. I wonder whether you want to reflect on that, given that it is in the report. I am very happy to, convener. We set out at case study 4 the history of mental health service provision in NHS Tayside, the very well-documented challenges that the health board was having, the challenges and relationships that it was having with the service users and the local community, and then STRANG's review of services followed by the independent oversight. I think that what we have tried to do is set out a fairly factual assessment of the current circumstances and progress. Although there has been progress in some areas, it is also perhaps worth just to record that we note that there are also areas for little progress that has been made in respect of governance public performance reporting, which perhaps speaks to the point that you are making, and still work to do in terms of building trust with communities who are using the service. We have an audit role in some of this, so we are continuing to track progress again that the board is making through the annual audit. Again, we are given thought to when would be the best time to undertake some further parliamentary reporting on that, alongside opportunities that exist in our wider NHS overview reporting. Given that we are reflecting on that, none of that says that the audit role is only one component of it, convener, that accountability for progress rests, yes, with the health board, the accountable officer of the health board, with the IJB and their local authority partners. How best to characterise it? I think that there has been progress in some areas, but it is still important work to do. Again, we look to set out that fairly factually in the case study of the report. Thank you very much. I appreciate that response. We are press for time. Willie Coffey, have you got a question you want to come in on? I will bring you in next, and I will bring in Sharon, and I will bring in Graham if we have time at the end. Thanks, convener. It is just one question that I have, Stephen. It is about the 10 per cent target to deliver front-line and mental health spending by 2026. It is the misunderstanding of the lack of clarity between what counts as front-line and what counts as mental health services so that we can properly account and report that. Can you say where we are with that and are we making any progress and making it a bit clearer for the boards and someone to be able to report for us? I will do my best to set that out for the committee. We cover this paragraph 67 to the report where reflecting the Government's ambition that, by 2026, 10 per cent of front-line spending by NHS boards should be on the mental health service provision, and NHS boards were asked to, in their current year delivery, annual delivery plans, which is a return that boards make to the Scottish Government on their intentions required to see what their current percentage was. However, this resulted in confusion because the Scottish Government or boards did not agree or share the definition of what front-line mental health spending was. The Government is currently reviewing that to better define in its guidance what it considers to be front-line spending. I think that it is a little bit more about where we are currently at in terms of progress towards 10 per cent. There are some signs that are going back slightly on an overall assist definition, so some work to do, both in a definition and progress to the overall target. As the Auditor General said, this was originally expected as part of the annual delivery plans, but because of some confusion about definitions, that work is still on-going. The Scottish Government is currently working with boards to get those trajectories in place. We were hoping to see it just before we published the report. Unfortunately, it did not come through in time. Hopefully, in the next few weeks, we would hope to see those trajectories in place. OK, I look forward to that. Thank you. The Deputy Convener, Sharon Dowie, has got some questions. Thank you very much. Good morning. Paragrass 77 and 78, on page 4, to one of the report, raised concerns that pressure on staff is increasing because of high vacancy and turnover rates and difficulties in filling vacancies. It cites a national shortage of psychologists. Vacancies for general psychiatry consultants are the highest of all medical and dental consultant roles in Scotland, and vacancies for mental health nurses have been doubled between March 2017 and March 2023, and turnover layers reached a record high. What action is the Scottish Government taking to support NHS boards facing those issues? Eva, you can come in at the moment to say about the actions that the Government is taking. I will say two things first. There needs to be a comprehensive workforce plan so that health boards, the Government and their partners can work towards the delivery of the strategy. You are right, Deputy Convener, that our report builds on the views of those working in the provision of adult mental health services that the system is under real strain. We set out some of the vacancy rates, turnover and the fact that very specialist people are in short supply, so that health boards are competing for those skills. That has an impact on the services that patients are looking for and perhaps speaks to some of the regional variation elements that we have covered already this morning. The Government's steps, Eva, can say a bit more about what is planned and the timescales for that. Thank you, Auditor General. As Stephen mentioned, there needs to be a workforce plan. The Scottish Government is currently planning to publish a workforce action plan alongside the delivery plan for the new mental health and wellbeing strategy this autumn. Again, we haven't seen that yet, so we don't know how detailed that will be, but in that we would hope to see detail about how exactly they're going to tackle these really quite challenging vacancies and workforce position. I think another element that might be worth mentioning is that although the specialist roles are really, really critical, there absolutely needs to be a plan in place to try and address these vacancies. There's also a role for new, innovative, slightly different roles to try and ease pressure on those specialist services. Part of that is through the mental health and wellbeing services and primary care. We've illustrated in the report examples where boards are employing these newer roles to try and address some of those recruitment challenges. The Royal College of Psychiatrists also raised concerns during the audit that most NHS boards rely on locums who are not consultants to fill vacant consultant psychiatry posts. Do you know the extent to which this is happening and also whether an assessment has been made of any risk that that could present? We don't have that detail. That was a concern raised by the Royal College of Psychiatrists to us. They highlighted that as a challenge. They have the detail on that. The other thing that you mentioned about the workforce plan is that we're waiting on a report coming out. I'm always interested in whether the workforce plan equals funded places at universities and colleges. It's interesting. Do you know why there's not enough student coming into mental health nursing? It's an increase in funded places but we still can't get enough people in. I think that it's a really important area for the health system to resolve. I think that we touched on the report that NHS education for Scotland are involved in tackling this issue. Tackling it and being tackled is the important next step. Whether it's about promotion, interests, changes of behaviours of prospective students all have to be looked at. What we've set out in today's report is the circumstances that the system finds itself in. It is alert to it the effectiveness of their next steps and what their planned steps are. Yes, we'll be part of the funded action plan but it may be an area of interest that the committee might want to explore directly with those NHS bodies. Moving on to plans and strategic direction how realistic are the Scottish Government's commitments to increase the mental health directorate budget by 25% and ensure 10% of the front-line NHS budget is spent on mental health by 2026 given the financial constraints highlighted in your report? You're right. We highlight the financial constraints that the Scottish budget is facing and indeed we've done in many of our recent reports over the past 18 months or so. Ultimately, this will come down to prioritisation that the Government wishes to make and a parliamentary consideration of the budget. Whether that is consistent with the aims of increasing mental health service provision and primary care settings of spending will all have to be balanced up. Those are the levers that the Government and Parliament have at their disposal as they set priorities. What's clear, though, and I think that as we touched on in some of the earlier discussions about other parts of public services will risk not being prioritised while health spending is prioritised. We've talked for many years in our NHS overview reporting that the system as it operates isn't sustainable. Public sector reform has to move at a faster pace. Building on Christine's point from earlier, we have to get from a reactive part of the system to a more preventative spend that requires NHS councils, IJBs, third sector providers to come up with a different plan than the one that we are currently operating on. However, it goes back to choices and priorities, Deputy Convener, to continue progressing with this and will require prioritisation that may not favour other parts of public spending. I wish to back your comment on difficult decisions that will need to be made. We note that a delivery plan and a mental health workforce plan are expected to be published by the Scottish Government this autumn, which will set out how the priorities in joint mental health and wellbeing strategy published will be achieved. Do you have an update on the timings of the publication of the documents? I don't think that we do. I think that we are optimising the most up-to-date information that we have, so I assume that the committee will be very keen to see that it is consistent with the findings and recommendations that we are making in today's report. Can you tell us more about what the Scottish Government alongside social care partners could learn from NHS England to improve its financial workforce and operational data in relation to mental health services? That was in paragraph 9 to 8, page 47. Thank you. I think that what we try to do in the report is to another audit work that we are under is evaluating where there are options for applied learning from where it has been in other jurisdictions. I think that the one caveat that I would make before saying a bit further and Lee again might want to say a bit more about how NHS England is operating is that we have not seen any perfect model, so whilst we draw on NHS England and one of our case studies from GES in Italy about the provision of services, we also note that there isn't a perfect set of circumstances for the provision of high quality mental health services. What we have seen in England and Lee can say more is that their use of data is at a further and longer starting point than we have seen for NHS Scotland in terms of primary care. Building on that learning, we know clearly that NHS Scotland speaks to their colleagues in NHS England to bring some of that back. Can that be applied successfully and effectively here in Scotland too? Lee. Just to build on what Stephen was saying, I think that it's important to recognise that NHS England still faces a number of data quality and completeness issues, so again it's not perfect, but they are collecting a greater range of data than we currently have available in terms of spending activity across a range of different services looking at inequalities as well as one of the things that they look at is a recovery rate for people who have engaged in some psychological talking type therapies. So I think that what we're just trying to say in the report is that we could possibly learn something from NHS England in terms of the range of different data that they currently collect and the different types of things that they're looking at. Okay, thank you. Right, thank you very much. We are very tight for time. Graham, if you've got a very quick question, you can have the final question. Thanks, convener. It will be quick. It's something we've not touched on yet, and that is the cost of drugs to treat people with mental health problems. I read recently that there's been an explosion in the use of antidepressants. We're now up to a million people in Scotland. The million adults in Scotland are on antidepressants, which almost gets us to that one-in-four figure that we mentioned earlier. There's a huge cost to all this as well, and I just wonder whether you've done any analysis of that. I recognise the reference you make to the cost of antidepressants. I think that we saw some commentary around that over the past couple of weeks. I think that we mentioned earlier that we didn't focus on individual conditions during the course of the audit, but a Paragus 75, what we've set out in it is perhaps not the expected result. We said that spending on mental health medicines in a community setting fell in real terms, Mr Simpson, from 117 million in 2017-18 to 90.4 million in 2021-22. At the same time, we're seeing an increase in the number of items that are being prescribed. It's consistent with the point that you make, but it leads us to a conclusion. We've not done audit work or evidence, but an interim conclusion that the cost of medicines for some conditions may have fallen, but the scale of access is still high and increasing. The cost of the medicine is falling, but the number of people using them may have risen. That's something that we should look at. Thank you. Auditor General, you for the evidence that you've led this morning along with Lee Johnson, Eva Thomas-Tudo and Christine Leicester from the Accounts Commission. Thank you all very much for giving off your time and your thoughts and your reflections and giving us some useful evidence that we will now consider and decide what next steps will be on this hugely important area. I do think that this is one of the strongest reports that you've produced. My time as the convener of the Public Audit Committee is clearly driven by the evidence and has reached some pretty stark conclusions. I think that all of those as members of the Scottish Parliament will need to reflect on. Thank you very much indeed and I will now move the meeting into private session.