 Good morning and welcome to the first meeting of the Health and Sport Committee in 2018. I hope everyone had a very nice break and wish you all a happy new year. Can everyone ensure that the mobile phones are switched to silent please? Of course, you can use them for social media but not to photograph or record proceedings. The first item on our agenda is an evidence session on the draft budget 1819. The committee's approach to scrutiny of the draft budget reflects the approach recommended by the budget process review group. The approach entails addressing budget implications throughout the year and bringing that information together to inform a pre-budget report for consideration by the cabinet secretary. We issued our pre-budget report on 13 November and the report set out some recurring themes and issues that we identified in relation to the Scottish Government's draft budget. The timing of report in advance of the publication of the draft budget was to enable the Scottish Government, if it chose to endorse our recommendations to implement in the draft budget. A response to our report was received from the cabinet secretary on 12 December. I welcome to the committee Shona Robison, cabinet secretary for health and sport and Christine McLaughlin, director of health finance at the Scottish Government. We have apologies from Paul Gray, who is unable to join us today, and the committee also has apologies from Alison Johnson. I invite the cabinet secretary to make an opening statement. Thanks, convener. Happy new year to you and the committee. I welcome the opportunity to give evidence this morning on the budget proposals for our national health service. As we start 2018, it is an important year as we look forward to the NHS turning 70 years old. We also look forward to Scotland's year of young people. In this context, I am grateful this morning to have the opportunity to discuss with you how we ensure that the NHS, our most treasured public service, is equipped to serve the people of Scotland, both now and for the generations ahead. In terms of equipping the NHS through investment, this Government has committed to increase the health resource budget by £2 billion by the end of this Parliament. In 2018-19, we take a further step towards this, with the resource budget increasing by over £400 million, which is an uplift of 3.4 per cent. We will continue to prioritise investment in front-line services, and therefore investment in our front-line NHS boards will increase by 3.7 per cent or 2.2 per cent in real terms. It is important to emphasise that the additional funding for our NHS is provided as part of our twin approach of investment and reform, recognising the increasing demand and expectations placed upon our front-line services and being clear that the status quo is not an option. It is through this approach that we will see more care delivered in the community through primary and social care services, and we will deliver our triple aim of better care, better health and better value. As we equip the NHS through additional investment, this Government recognises that staff in our health and social care services do an outstanding job in caring for the people of Scotland. We have seen that particularly over the last few weeks as they deal with winter pressures. It is right in fulfilment of our programme for government commitment that hard-working NHS Scotland staff receive a pay settlement that acknowledges rising inflation. Our draft budget reiterates our commitment to this that will lift the 1 per cent public sector pay cap and provide a guaranteed minimum pay increase of 3 per cent for all public sector workers who earn up to £30,000. We will also be mindful of any developments for NHS staff elsewhere in the UK to ensure that our health service staff are treated at least as fairly as those in any of the UK nations. Convener, we will make these commitments on investment at a time of significant financial challenge. Following the UK autumn budget, Scotland is facing a real-terms reduction in our day-to-day budget of £200 million in 2018-19 and £500 million by 2019-20. However, in the face of these real-terms reductions to our block grant, it is only possible to support our level of investment in the NHS without damaging other portfolios as a result of our proposals on tax. The draft budget sets out proposals designed to make our tax system fairer and to generate revenue in support of public services, including an NHS that remains true to its founding principles, free at the point of need and publicly owned and operated. A central component of the health and sport budget for 2018-19 is that it will allow for further progress in delivering our commitment that more than half of front-line spend will be in community health services by the end of this Parliament. The funding in 2018-19 is designed to support a further shift in the share of the front-line NHS budget dedicated to mental health and to primary community and social care. We are increasing the level of investment in mental health in CAMHS. In 2018-19, a further £17 million will be invested, which will go towards the commitment to increase the workforce by an extra 800 workers over the next five years for the transformation in CAMHS. I expect that this funding will be in addition to real-terms increased spending on mental health services by NHS boards and integration authorities, which is already in excess of £1 billion per year in 2017-18. Therefore, I expect that this budget will deliver an increase in mental health spent in excess of 3% and will support a shift in the balance of spending. Spending on primary care will be supported through the primary care fund, increasing to £110 million in 2018-19. This will support the transformation of primary care by enabling the expansion of multidisciplinary teams for improved patient care and a strengthened and clarified role for GPs as expert medical generalists and clinical leaders in the community. This forms part of our commitment to increase funding for primary care by £500 million by the end of the Parliament. In terms of spend on social care, in 2018-19 an additional £66 million is included in the local government settlement allocation to support additional expenditure by local government on social care in recognition of a range of pressures that they and integration authorities are facing, including support for the implementation of the Careers Scotland Act 2016, maintaining our joint commitment to the living wage, including our agreement to now extend it to cover sleepovers following the further work that we've undertaken and an increase in free personal and nursing care payments. A central part of our activity in 2018-19 will be a continued focus on our early intervention and prevention approach to public health, balanced by efforts to support everyone to lead healthier lives regardless of their circumstances. We're consulting on a new diet and obesity strategy and we're progressing measures to limit the marketing of products high in fat, sugar and salt, which disproportionately contribute to ill health and obesity. Addressing the use and impact of drugs is a challenge that is not unique to Scotland, but it's one that we are determined to meet and we've begun an overhaul of our drug strategy, guided by a principle of ensuring the best health outcomes for people who are or have been drug users, will expand scope to set out a new vision for alcohol and drug treatment together. As set out in the programme for government, this renewed focus on alcohol and drugs will be backed by additional investment of £20 million in treatment and support services. Our vision is also of a Scotland where more people are more active, more often, and the Active Scotland Outcomes Framework sets out our ambitions for achieving that and is underpinned by a commitment to equality. Along with additional investment of £2 million, we'll underwrite the potential shortfall and funding of up to £3.4 million for Sport Scotland in 2018-19, and we'll continue to encourage the UK government to take the appropriate action required to address lottery reductions. In conclusion, convener, I would like to conclude my opening comments emphasising that this is a budget to equip the NHS to serve the people of Scotland both now and for the years and generations ahead. I've set out again our twin approach of investment and reform, additional funding for health and sport, supporting fairness for all across society and delivering the reforms needed to equip our health and social care services for the years ahead, allowing people to live longer, healthier lives at home or in a homely setting. Thank you very much. Ivan, would you like to start? Thank you very much, convener, and thanks, Cabinet Secretary, for coming along to talk to us this morning. I want to cover off on a couple of issues around the overall funding, but I think that it's important at the start to make the point, obviously, that way that we're talking here about inputs, but what's important ultimately at the end of the day's outcomes, and I'll let on our discussion, we're going to focus on performance and a bit more detail. I'll leave that to one side and just focus, as I say, on the inputs at the moment. Just for clarification and for the record, looking at the numbers, I can see there's a £373 million cash increase in the budget 2018-19, compared to the previous year, and that translates into a £175 million increase in real terms. It's true to say that not only is there more cash going into the service, there's more money going in real terms as well. That's correct. There is a real terms increase, and that's in recognition of the fact that investment is important, but I think, as I said in my opening remarks, that investment, and that real terms investment, has to go alongside reform, which I think is what you're pointing towards in terms of outcomes. Those reforms need to make sure that every single pound of that additional money, and indeed the money that's already in the system, is delivering the most effective and efficient services. The programme of reform we've laid out over the last few months, focusing on the drugs budget, for example, on how we look at elective capacity and deliver that more effectively, and how we shift the balance of care to keep people out of hospital. It's a really much a twin track approach, and the resources that will be generated to be able to be reinvested through reform are equally as important as the real terms increase in resources. Just to clarify on that, because we tend to have a conversation about efficiencies as a word when we talk about health board spending, etc., but in that context of a real terms increase in the funding, when we're talking about efficiencies, we're not talking about it in the context of people spending less, or spending less in real terms. We're really talking about it in the context of people reallocating money from one area of spend to another, would that be a fair comment? That's right, and also looking to meet the increasing challenges. Although more money is going into the NHS in real terms, as I've said often, the demands upon our services continue to grow, particularly the demographic challenges, which means that we need to do things differently. Therefore, we're working very much with boards. Christine can give me more of the detail around how we ensure that our services are working in the most effective way, so a lot of focus on regional working, boards working together to do things differently, to use the capacity that we've got in a different way, to look at elective capacity in a different way, to make sure that looking at the drugs budget that there's a common approach to prescribing practice, for example, because there's variation there. As the chief medical officer has often said, the focus is on addressing unwarranted variations, so that all of our services are operating to the best. The resources that are then used more effectively are in addition, obviously, to the additional investment that the budget would deliver. Finally, to clarify on the manifesto commit, to increase the spend on the health service over the later in the Parliament by £2 billion, and so far that's increased by £743 million, which looks to be on track, given the inflation impact going forward. That's not far off the 40 per cent that you'd expect after two years. The real-term commitment was to increase by £500 million in real terms, and what we've seen so far is a £370 million increase over the first two years, so that looks like that's running far ahead of target. As far as you're concerned, are you quite comfortable that those manifesto commitments are on target and will be met over the course of the five-year Parliament? Yes, I am. This year's budget is a very important contribution towards that, in terms of that headline £2 billion commitment, but also in terms of being able to shift the balance of care, as we've laid out. This is a really big step in that direction. Just to clarify numbers overall and for the portfolio, there's an increase of over £400 million in cash in 1819. In terms of the £2 billion, it was still required to be additional funding in the latter years of the Parliament to meet that, but as you say, it is headed in the right direction. The other two key targets about primary care as a percentage front-line spend and about more than a half of front-line NHS spend on community health services, so we're seeing increases in those proportions that are headed in the right direction. The important thing will be the pace at which both of those measures increase over the next few years. It grows at a greater pace than it's at, and that's the importance of investing in reform, but certainly the information from our published data would suggest that we are headed in the right direction, and there are increases in both of those areas. I'm interested in NRAC allocations. I'm aware that the National Resource Allocation Committee calculates funding based on age, geography, deprivation, so rurality, which is important for me as a South Scotland MSP. The NRAC funding is often not decided upon until other allocations are made, so I'm interested to know if the Scottish Government is committed to NRAC and is it still considered to be the best way to allocate formulas? I'll ask Christine to comment on the detail in a second, but we have over the years and previous Administrations have had varying formulas that have applied and by that, it's fair to say that they've all been criticised in one way or another. The difficulty in any formula is that it has to be done over a longer period of time in terms of adjustments, otherwise you run the risk of destabilising other boards as you make that transition, but it's fair to say that the NRAC allocations that are planned for 2018-19 will bring all boards within 0.8 per cent, so I think that's the closest we've been for some time to parity. I'll ask you to give me a bit more detail on the first point of what you were saying, because I didn't quite understand it. In our briefing papers, it talks about how NRAC funding is calculated, but it's often based on... Scottish Government makes various adjustments to the allocations before assessing progress towards NRAC, so I'm curious as to how we get parity with certain allocations across different boards. I would probably need to go into that in a bit more detail, but just at a high level on NRAC, NRAC is the basis of all the recurring funding to boards, so it is calculated as part of the budget and updated on an annual basis, so it isn't something that's an afterthought, if you like. We've always had an approach that says that we didn't want to destabilise any board, which is why movement to parity is over a long period of time. Last year, we were at no board, but it was further than 1 per cent from parity. Sorry for 17-18, but in 2018-19, the extra funding moves us to no board further than 0.8 per cent, so that is the closest we've been to parity since NRAC was introduced. Eight boards will receive additional funding for the being behind parity as a result of the £30 million going in. There is a component of our funding, which is maybe what you're talking about, that doesn't go out on NRAC, which is all of our programme. It spends on things like funding for health visitors. For instance, there is a large component of additional funding in the system, which has been given out specifically to meet the agreed increases in health visitor numbers in different parts of the country. One of the issues is the extent to which there is still some funding that doesn't sit within NRAC. It's also not a formula that applies and can apply to the eight national boards either because they're not population-based in their services. To answer your question, there are always opportunities of looking at different ways of funding the system. If you look at England with payment by results, you've now realised that in a system under pressure, a volume-based funding system isn't always the right way to go. We can all learn from each other. One thing that we've discussed looking at more in our system is the extent to which you can incentivise the performance and the outcomes that you're looking for rather than just the population that you serve. We're always open to looking at that in more detail, particularly with health and social care integration, when you've got a different funding model for local government. I would say that whenever you introduce a new funding mechanism, it takes quite a long time to do all the research to look at different options. If you do not want to destabilise your system, it is a long lead-in time before you seek change. It's not to say that we shouldn't look at it, but it would be quite a few years on probably before we would introduce something that was markedly different from what we've got. Thank you, convener, and good morning to the panel. I wanted to touch on the area of capital budget. The proposed Scottish Government budget looks to do a reduction of £70 million in the NHS capital budget. Given the backlog of repairs that we know already exist, I wondered if you'd like to comment on whether or not that was the best use of resource. First of all, the important thing to say about capital budget is that it fluctuates from year to year. What we've seen off the back of 1718 was the conclusion of a number of big capital projects. Capital budgets will reflect where you are in the cycle of capital build. I'm sure that Christine will say a little bit more about that. Within the priorities for capital investment, we'll be making sure that essential repairs and maintenance are carried out and that the boards are supported to do that. In addition to that, some other priorities, for example, the Scottish Ambulance Replacement Programme, Radiotherapy Equipment Replacement, the NHS Highland Theatres Upgrade, the Electrical Upgrade at Ninewells, among some other local projects. Christine, do you want to say a little bit about why the capital budget fluctuates? We've had in December the opening of the Dumfries and Galloway new royal infirmary, which is a fantastic facility. That was one of the reasons why our total capital budget in 1718 was higher than going into 1819 because that's now complete along with the Scottish National Blood Centre as well. Just for assurance about 1819, the capital budget covers all of our planned commitments for 1819, so there is nothing that we've had to pull back on in 1819, so that reduction reflects our planned spend. It covers what we expect to spend on elective centres, initial work on the Baird anchor and the Balfour in Orkney, so all those core programmes are covered. Every year, we give approximately £150 million core funding to the NHS boards for maintenance and minor replacement, and we expect that to stay at fairly static levels. Back to your point about the level of maintenance in the system, so backlog maintenance has stayed fairly static for the last few years. The latest figure was £187 million. General wisdom is at the best way to deal with backlog maintenance, and a significant sense is by replacement and rationalisation of sites, and that's been our approach. For next year, approximately £60 million of funding that goes to boards will be to reduce backlog maintenance, but as you'll appreciate, as you deal with something like reducing backlog maintenance in Dumfries, you then have an increase in backlog maintenance costs in Ninewells because of the electrical issues that we're investing in for next year. There will always be things that come off the list and then get added. There are some fairly large potential investments coming up over the next five to ten years. We've got initial business cases coming in for things like the Monklands replacement in Lanarkshire, an IPvillian replacement in Lothian, and potentially a case for a new south-east cancer centre in the Lothian area. We'll be looking ahead to the pipeline and to see how we manage to build those into the overall infrastructure programme for the Scottish Government. In terms of those projects, when will the Government publish or undertake a strategic review of projects like that? In Lothian MSP, I've been involved with the Edinburgh Cancer Centre, and there's £26 million going towards the backlog of some of it that's very significant for that centre, but it's quite clear for the whole south-east of Scotland the new centres required. In terms of that scoping work taking place and prioritising projects across the country, how's the Scottish Government working on that and when is that likely to be brought forward? One of the recommendations from the Audit Scotland report was the development of a capital investment strategy, which is under way just now. What we've said to boards just now is that we don't expect any cases to come forward to the capital investment group for consideration without having, as a minimum, being part of the regional plans for all areas. We're not looking for individual board submissions to help us with that prioritisation, and we're just consulting with the system about setting up a national infrastructure board to allow us to prioritise nationally. That would deal with precisely that issue that you raised, but I'm well aware of the situation and the balance between investing in maintenance of the existing cancer site versus investing in a new one. Partly that's timing, and there's some work that we need to do just now that can't wait for a couple of years, so that's the balance in deciding to invest now in existing cancer services. In relation to the NPD projects or the papers that we have said that the changes mean that they can continue to be treated as private sector projects in terms of accounts and operation in the way in which they're structured, there's very little difference between NPD and PFI in that regard, would that be correct? What we're saying is that we've resolved the accounting issues for the NPD, but the main difference in the way that NPDs are structured is that I think that there's a mechanism to deal with generation of profits and how that fund is resolved, so it feels like the level of risk and the balance of risk is more where we would want it to be with the NPD projects that we have in place. Do you think that we need to change the name of it because non-profit distributing would suggest that there is no profit to be distributed when, in fact, there's very significant profit to be distributed, so do you think that it's a misleading name? Well, they're now classed as publicly owned and therefore require capital funding, and you'll know the history of the position that the ONS has taken. I think that it probably is helpful to track back which projects were funded through which pipelines, and therefore we wouldn't be intending to change the definition. I'm not disputing that, but if you said to somebody that we have a project in which there's a non-profit distributing system, they would say, well, there's no profit to be distributed when that's far from the case. I think that people are generally confused, just by the names of PFI, PPP and NPD. I think that looking back what might be helpful for us to do, particularly now that we've got some fairly substantial NPD projects, is to look at the way in which they are operating compared to some of our earlier PFI deals, because we're always looking to try to get that balance feeling like it's in the best inches of all parties involved. Absolutely. It's fair to say that a lot of progress has been made from the earlier PFI projects, despite what you're saying to me now. I think that the levels of the poor deals that were struck in the early days are some that we're still paying for. Unfortunately, in great numbers and I can't remember what the current figure is that we're paying out for PFI, but it's substantial. What we would say as well is that part of some of the work that we've done this year is further reviews of the earlier PFI's. We've generated almost another million pounds just from looking at the annual contract values, so there's still more to go out particularly with, as you said earlier. PFI's will be where we're looking at things like whenever there's opportunities to buy out things like domestic services, as we did in the Royal Infirmary in Edinburgh. We always need to keep a really close eye on those deals. The NPD deals seem to be structured in a way that feels more appropriate, but yes, it involves private sector funding, and I don't think that we're seeking to hide that. I think that there's maybe some more detailed work that's done on that to assess whether they are as good value as people portray them to me. Alex Thank you, convener. For the first time, the money for social care is being paid directly to local authorities rather than going through the convoluted route of the health service. Given the presumption against ring fencing, how are we going to keep tabs on this money, particularly when this budget covers the 3 per cent uplift in the health service, but the wider budget doesn't cover the 3 per cent uplift in local authorities? There's almost a flat cash settlement for local authorities. How will we stop local authorities seeing this as an easy way to meet some of their 3 per cent obligations outside of the social care workforce and make sure that this is spent on social care? If I could just say first of all that the £66 million that's got to be seen in addition to the £550 million that is already in the system that has essentially been resources that have passed through the health budget to support social care, and that is now recurring money within the system, so over half a billion pounds. I think it's important to see against that backdrop of substantial resource. What we have discussed with COSLA, a local government, is the priorities around that. £66 million laid out in my opening remarks to cover commitments such as the carers legislation, the living wage, including sleepover, and the up-rate to free personal and nursing care. There's a common commitment to those priorities. The local government has agreed with us that paying and maintaining the living wage to social care staff is an important part of recruitment and retention, so it's not in their interest to not do that. It's a common commitment and common interest to make sure that those priorities are delivered. You're right that we don't ring fence as such, but we have very clear agreements that that is the focus and purpose of those resources. We have no indication from COSLA or any individual local authorities that they don't share those joint priorities for the delivery of that money. Is there a process for monitoring that adherence to those collectively agreed priorities and for pulling in local authorities that perhaps aren't spending the money as they should be? We do that through regular meetings with COSLA, and I also meet very regularly with local partnerships. It tends to be with not just the local authority but the chief officer of the integrated joint board, often the NHS chief exec as well, so we tend to meet on a partnership basis, so we would continue to do that. Plus we have the ministerial strategic group that I chaired jointly with COSLA that oversees the delivery, if you like, of integration priorities, so I think that we would pick up quite quickly if there was a local authority that, for whatever reason, wasn't going to deliver, for example, maintaining the living wage. I just don't think, though, that it would be in their interest to do that. Why would you invest in the living wage to date, and then suddenly not? Why would you not address the issue that we've all been working on to address the issue of sleepover, for example? It would be counterproductive for any local authority to not do that. It's a mature relationship, and one that is based on these jointly agreed priorities, but we would pick up on Christine. You meet very regularly with your financial colleagues within local government, and you would get a sense if there was any issue with that. If I could maybe pick that up in relation to the report that you produced in December, and there's a lot in that, obviously, on transparency, and there's a number of measures that we have kicked off to introduce to make that easier to understand and to get that kind of information about spend and planned spend. From February, we've agreed with integration authorities to start a consolidated reporting on spend. As part of the budget, we'll be looking to gather that information on the planned spend on all those key areas. I know that you've used ADPs as an example about getting better transparency about the spend. We all want to see what the outcomes are to, but trying to get better understanding on things like mental health, spend and primary care community. That's something that would also allow us to see very clearly whether social care spend is going up, down or staying the same. It gives us an easier way in to start to look at that and understand why that might be the case. In some cases, there might be some genuine reason, so there might have been a one-off investment in one year that is therefore not included in the next year. The approach that we're taking for next year just allows that flexibility for the system to calibrate, and if it doesn't, we would seek to understand why that was and whether there was any intervention that fell up. Sandra Yedle. Thank you, convener. If I could just come in on that particular point, when you mentioned about in February, I don't know if you'd be reducing the report or if you'd be looking at it then, because that was a concern of the committee, that there was no update on that. Do you have any further updates on when that would be produced? In another issue that I wanted to come in earlier, you mentioned about community care, and it's very difficult to extrapolate how much has been spent. There's really two questions on that. Do you have an update of when you'll be able to produce the figures and would you be able to extrapolate how much money from front-line services is spent on community services, such as health officials? We've tried to find out what's going on with an integration authority, and it's been extremely difficult. My question is, do you know what's going on? What role does Parliament in this committee and others have in monitoring what's going on if we cannot find out? A lot of work has obviously gone on in this area, in particular in response to the issues raised by the committee, which I think you were just going to come on to. I'm trying to cover a few of those points. Your first one, the integration authorities, we're working with them to have a first pass of a consolidated report in February. It will probably be January data, but in February. I'm part of that, too, to look at it to see whether it gives us all what we're looking for, because it is absolutely true that you can go on to every integration authority website and you can look at their board papers. That's not the same as trying to get a consolidated picture. I suspect that, when we start to do it, we'll find that there are some inconsistencies that we need to then iron out, but our first pass of it will be February, to have that. That's what we've agreed that we're working to. Your wider points about things like community spend. Right now, the information that I started off with saying that we're seeing it moving in the right direction that we're taking from the annual cost book, which is probably too far back for all of us to feel particularly satisfied with. By introducing routine reporting, we'll be able to measure those key areas about primary care spending and about community services spend on a regular basis, I hope, quarterly, to have that. I don't see any reason why that wouldn't be something that we'd want to share with whoever we wanted to have access to and just make it publicly available. We'll make sure that we send that on to the Committee Pro-Act. The third strand, I would say, is—again, we discussed this at the time of the Audit Scotland overview report that we were planning on developing a financial framework. We're doing that work right now and that will include social care data as well. We'll be looking to the medium term to be able to set out our expectations on funding, on expenditure and on reform for health and for social care. We've designed that so that it helps us to answer the questions about shifting the balance. All the points that you raised in the report, I have the same difficulty in trying to get that single picture. I can go to individual parts of the system and I can ask for it on a reactive basis, but it's not there in one place and that's what we're seeking to put in place. My only slight caution is that, the first time that we do it, it will probably show us that some things look odd and it will probably be because people have put them in different places, so we'll need to do a bit of work to tidy it up, but I'd like to give you that assurance that that work is well under way. Who will be doing it and who will be reporting it? The consolidation on a routine basis will be undertaken by the integration authorities and that will be information that would then be publicly available. We'll still work that through about whether that's something that gets published on our website or whether it's just a local consolidated information. The financial framework is something that we've committed to publish in spring. I think that we're really concerned about the end of March, beginning of April, to do that and I would think that that would be something that the committee would be interested in. In terms of the consolidated information, when are we likely to get that? So that's the same. The first pass of it will be February, so maybe be March before we would have it in a state that would be fit to publish, but I wouldn't expect it to be any longer than that. I was also going to make the offer and develop the financial framework that, if I and the committee want to give us some thoughts on that before it's published or you're speaking to Spice or whatever, then we're more than happy to take those comments on board because we're trying to deal with all the issues that people have raised about it's hard to get the big picture, it's hard to understand what things are moving in the right direction and we're working hard to try to simplify that and make it as straightforward as possible, so be happy to get your thoughts on that. Okay, thank you. You're okay, Sandra? Ash? Thank you for being here. Good morning. Under the health board allocations, the line for the transformation change budget that's gone up from £38 million to £145.7 million, so that's quite a significant increase in that budget. Can you explain what type of thing you're anticipating is going to be achieved with the extra funding that's been given to that? Maybe you could give an example of the type of things that it might be to fund? I'm going to give you headlines and Christine can come in with some more of the detail, but the transformation fund is important in that we have listened very much to boards in the way they're telling us that actually making change and shifting resources, doing things differently, can sometimes be quite challenging and the transformation fund is a way of helping them to do that by driving some of that change and funding it through that transformation fund and so the priorities for that are around the shifting the balance of care, making sure that they can shift and build up those community health services, so the primary care, a key priority for that. Looking at more regional working, so Christine mentioned earlier on that the message we're sending out to boards is that their plans really need to have a regional dimensions on both their capital outlook and also on their resource spending, so for example they're looking at the development of a new hospital that shouldn't just be about what that would do and services it would provide for that particular board, it should be about what impact could that have in that region. In terms of resource spending we would expect transformation to be showing the shift in the balance of care, shift to primary care spend, to mental health spend, to make sure that for example the work around the drugs budget and looking at more effective prescribing, that this fund is really to help gear up and accelerate the pace of change that we need to see and we made the decision that that was best done through a funding stream that would help boards to do that. Christine, do you want to sell a couple of other examples of what will be in there, so things like the improvements in elective care, through elective access collaborative would be funded through that investment in digital, so we will have the launch of the digital health and care strategy this year, so receiving some funds for investment in things like that will be really important. We've also got work underway on radiology, shared services, we're moving on to labs now and work on shared business systems across the system. This is all really underpinning the health and social care delivery plan in the milestones within it, so it's really just trying to carve out some funding on a non-recurring basis to support that fund and in addition to that we've got the single largest investment in primary care and mental health transformation. We've deliberately not allocated that out on an individual board basis, that's one of those examples that hasn't gone out on an NRAC basis because there'll be some things that we will fund once for the whole of the system and others that will be on a regional basis. We'll be getting the next version of the regional plans from the three regions and from the national boards in March, and we would seek to use that as a main basis in which we would decide to allocate funding, but we do expect that funding to go out to boards and integration authorities in here. So the boards will actually maybe come to you with a proposal of what they would like to spend the money on and then you'll evaluate that and decide where to allocate the funding. So for instance within the national boards we know that one of the biggest propositions that you're working on is about digital, particularly how NHS 24, Ambulance Service Nes, can all come together to provide digital services. So we would expect there to be one funding stream for instance for something like that same with the business systems. The work on on radiology is again being done as a national programme so it won't be something that will be allocated to all boards but we do expect all of that money to be to be used within the system directly next year. Okay thank you. In some of that transitional money I mean would that be allocated towards bed space because there's huge demand on beds at a time when the policy is to reduce people being in hospital whilst the social care system is not functioning as it should be to get people out. So is that an area where some of that transitional cash will go to maintain bed spaces as demand increases? Well it's about making sure that the system is in balance and that has to be done carefully. A lot I would say is that you know the acute bed reduction that we've seen over over many years has really been mainly due to the different way of services being provided. So day surgery for example we're now seeing people have operations in their out within 24 hours that just wasn't the case I was going to say 10 years ago but even five years ago. So the way that the beds are used is is different and therefore we have to make sure we get the right number of acute beds where there are two main areas of reform here. One is on elective so making sure that the way we deliver our elective services is as efficient and effective as it can be and that's the work that Derek Bell is undertaking looking at how we make sure with the plans for the elective centres that we maximise the best way of delivering elective procedures and that is going to be done on it with a regional focus as well. The other area is unscheduled care and without a doubt you know the work that's going on to reduce unschedule admissions and also reduce a delayed discharge will release capacity within the acute system but it's about you know it's about putting things in the right order and obviously we have to make sure that those reductions of pressure within the system and therefore reduction on bed pressure are happening before you would you know do remove any acute capacity so it has to be done in a way that is shifting the balance of care but doing it safely and making sure that both systems remain in balance but we do know that there is use of the acute system that is being used by people who would be better treated elsewhere in a different setting and that's really where the focus of the next few years is going to be. So I'm still not very clear is that where some of that transitional money will be put into or not? Well the transitional money is partly about building those services up to make sure that we can ensure that those services in the community are reducing pressure on the acute services so it's about doing things in the right order that's why there's a huge chunk going into primary care to make sure that those services are being built up trying to reduce admission to hospital, reducing delayed discharge so that people who are in an acute bed that don't need to be there are not there so that that releases pressure on the acute system. What there won't be though is a you know we need to make sure that given if you were to do nothing we would need far more acute beds going forward need to build you know a huge number of new hospitals but you know if we're going to do that we wouldn't be able to also spend that money on developing community services so this is about getting the system into balance it's not about the wholesale closure of acute beds it's about getting the system into balance so that we can cope with future demands on the system because we don't we you know we can't invest in community services and then build a whole new generation of of additional hospitals because there's just not the resources to do both so we need to make sure that our acute system is able to cope with not just current demands but future demands as well. Prior to Christmas we saw for example edinburgh up front saying we're sending people home but with no appropriate social care package in place because we can't keep them in hospital and st john's hospital at the weekend they're sending cancer patients home who were supposed to be in hospital or being sent home now their bed capacity is not there now that's what i'm asking is that is if a board put forward a proposition for more bed space as a transitional option would that be funded? Well first of all there will be more bed capacity through the elective centre so the elective centres are going to provide additional capacity in the same way as the golden jubilee operates for elective procedures that are not interrupted by the flow of unscheduled patients but let me say something about the cases you've cited. Could you answer the question though if a board applied for transitional funding for more bed space would it be granted or not? Well they would be unlikely to do that because it runs and flies in the face of the direction travel we can't say we want to shift the balance of care and then put the money that was going to be going into shifting the balance of care into more acute beds but if i can say to you very directly you can't measure the demand for beds based on the midst of a winter period of exceptional winter pressures that you can't do that you have to look at acute bed capacity over the course of of the year you can't look at it in a two week period and say that is what is needed in terms of acute bed capacity what you need to do is to make sure you we build that into winter pressures and we have done that although this year there have been exceptional winter pressures and can i say in terms of what you cited about social care people should never be sent home without any support what sometimes happens is that people are sent home to be assessed at home so that they can be assessed for their social care package within their own home environment rather than within hospital what i would acknowledge though is that the pressures within the royal infirmary and st john's partly are exacerbated by the issue of delayed discharge within the lodian system the lodian system at the moment accounts for about half of all delays within scotland so there is a particular problem that you and i both know are partly to do with the inability to recruit care staff the local market concerns within the city of edinburgh and we are working very very hard with those partnerships to overcome those particular local pressures and looking at really innovative solutions but you have to base your acute bed capacity on what is required throughout the year not just on what is required within the winter period nobody's suggesting it was just the winter periods i certainly wasn't calling thanks convener and good morning to the panel as things currently stand at the budget specifically proposes a 1.8 per cent increase in funding for local health boards and some increases are actually as low as 1.5 per cent on freezing galloway and the scottish borders and all given that the most recent estimates suggest that health inflation is about 2.3 per cent this year and estimated to be 2 per cent next year and that's before you take into account the government's proposed pay policy would you accept that from a health inflation point of view that this budget is actually a real terms cut for local health boards? No i certainly would not as i said it's a real terms increase a 2.2 per cent real terms increase and actually you know in terms of done freeze and galloway if i'm not mistaken i think they are a an enrack well they are already above enrack parity quite well above enrack parity in fact what i would acknowledge though is that there are additional as well as general inflation there are additional pressures whether that's like the drug's budget for example is one and that's why it's not just about investment and upfront investment in our health service as we are doing it's also about reform and changing the way we do things so it is important for example that prescribing practice is is the best and is common throughout Scotland rather than differing practices in differing areas that we need to make sure that every pound of investment is being used as efficiently and as effective as possible and that's why when we talk about investment and reform always in the same sentence because in order to make sure that these pressures are able to be met and at the same time the transformation of services goes ahead then as well as the real terms increase the funding it will require those reforms in order to release resources to be spent in a more effective way christine do you want to say something about the inflation point so so overall the funding for bores is 1.8 but you're right that we've done a minimum of general inflation which is 1.5 per cent and this comes back also to the the consequences of a formula so based on the formula Dumfries and Galloway is overfunded i know that Dumfries and Galloway will not feel overfunded but the formula that that's the reason for for the 1.5 per cent so unless we start to put additional money into the bores that are below parity we won't reach that sense of of parity because what we don't want to do is take money from boards and i don't think that that's anything that anybody would would support us doing so that that 1.8 per cent is above general inflation i would think that everybody accepts that real terms when we talk about real terms is based on general inflation it's a measure that government use audit Scotland in the report i think are content to reference general inflation as the way in which we calculate real terms so i think it's true to say that there's a real terms increase but at the same time as cabinet secretary says to acknowledge that there are other other pressures on the health and care system which are over and above that and that's why we're investing so much in reform but it does also mean that the system will still require to make savings of a similar similar level than they have up until now because of that position until until the system finds a way to recalibrate so you're not you're not wrong in what you're saying about the pressures in in the system there are different ways in which people calculate health inflation from anything from from 2 per cent to four or five per cent depending on what you include within it so that i wouldn't deny that there are further pressures beyond general inflation but i think there is a real terms uplift in the system and there is additional funding for reform which is £175 million and that's why it's really important that we do find a way to use that not to fund existing pressures further but to get that change that we're looking for so if anything that we can do that mean that people can be treated outside of the acute sector it's got to be something that takes us in the right direction as we do that and that's what we really need to make sure that we invest that that total funding and transformational change to get that best return over the over the next five to ten years i think in all that you've confirmed that the uplift to local health boards is 1.8 per cent and whatever way you look at health inflation it's above that figure but can i look specifically on including transformation is 2.2 per cent no because that money will go out to boards it's just kept with respect we don't know what that allocation to health boards is we've just touched on the point that you appear to suggest that Dumfries and Galloway gets too much money but you have no idea how the transformational change fund will be allocated so you know you can't take that into account as allocated to local health boards when you actually specifically have already said that's for additional pressures not current work that's being carried out but can i look specifically at one of the the main pressures on health boards which will be the the pay policy no spice of estimated that will cost about 170 million pounds in the forth coming year do you agree with that figure and has that figure been taken into account in your allocation of funding to health boards so so let me just say a couple of things first of all Christine McLaughlin didn't say Dumfries and Galloway had too much money what she said was it was a an enrack it was above enrack parity now you know i'm sure that you know around this table there are members who represent boards that are below enrack parity so what i need to do as the health secretary is to balance that because regularly i get asked in the chamber from members representing Lothian or Grampian about being under enrack parity so you know we have a system here that has to be fair to all and that means that there has to be a formula that gradually makes sure that all boards come to parity so there's not about whether a board has too much money it's about where they are in terms of distance from enrack parity in terms of pay the the i've laid out in my opening remarks the position on pay the we have resources within the budget for that will go towards the pay settlement however we have taken on face value what the treasury have said and that is that the recommendations from the independent pay review body will be fully funded from that and that will mean that we will get consequentials that we would expect to flow from the treasury in terms of helping to meet any pay review commitment that comes from the independent pay review body and what we have said is as well as setting out our pay policy that we will make sure that staff in scotland are treated at least as fairly as staff in the rest of the UK so it is an unusual set of circumstances this year because we are awaiting essentially a pay review body which will then have consequences for the level of funding that flow in order to meet that pay policy so you know i think that is you know something we've no probably not faced previously in terms of the way pay has been funded but that's right so to clarify your figures are the same figures that we are working to that the the impact of the the pay policy is is just under 160 million pounds if that was applied to the nhs in scotland next year boards would have always been planning on a one percent increase which is about half of that so that's already factored into boards plans for 18 19 so the unknown is the extent to it the pay review body recommendations for the nhs and the extent to which there are additional consequentials flowing from the UK government position and we won't know that until we don't expect to know that until about june of this year but the question was does your allocations to health boards take into account what is currently your proposed pay policy which is a three percent rise for the nhs staff does that take into account the 170 man point is that taking account and the funding you provide for health boards but you touched on the issue of potential consequentials and barnock consequentials from the UK government depending on what they do with regards to to pay for the nhs in england so are you specifically saying you will give a commitment to fully allocate all barnock consequentials to the national health service in scotland that come from any additional funding that goes to the nhs in england all consequentials will go on and the fact that the previous question does your allocations to health boards taken to account what is your current preferred pay policy minimum pay policy which is to provide a three percent rise to nhs staff well as christine has set out we've boards have already got an element of that pay policy built in but you know the final pay policy as it lands will require us to utilise consequential resources that would come in terms of the independent pay review body what we have said is that we will make sure in the resources that we allocate that are partly already allocated and will be allocated will make sure that staff in scotland are receive at least as fair a settlement as the rest of the UK in terms of the independent pay review body but we don't know what the independent pay review body is going to say as yet so we will have to wait and see what they say before we know what the final cost will be for that pay review settlement so you know it is a unusual set of circumstances this year which requires us to try to predict to some level but you know we will have to wait until we see what the independent pay review body says i have to say i'm not entirely clear how you're actually proposing within the budget you've set out draft budget to actually meet what you say is the minimum three percent pay rise but can i can i look specifically then if you're not going to say exact whether or not that funding is built into allocations already proposed for health boards for nhs pay let's look at the issue of social care pay then given the fact that we do have integration with health and social care now the draft budget proposes to council funding by 135 million pounds in real terms in whatever way you want to define real terms that's a fact now at a time that social care demand is obviously rising and you've actually said that answer to a previous question that your 66 million pounds that's contained within frankly a cash flat local government budget is allocated for things such as sleepovers, living wage, the free personal and nursing care payments and the carer strategies so that's effectively ring fends or supposed to cover those particular areas so where exactly is the funding coming from to meet an increase in pay for social care workers well first of all as i said earlier the 66 million pounds is in addition of course to the 550 million pounds that's already been invested into social care via health resources so over half a billion pounds is already in the system working now to improve social care provision and indeed has helped to deliver the living wage for non-council staff the 66 million pounds that you've referred to is additional money in 2018-19 that will help to meet the commitments that I set out including the up-rate to the living wage for non-council staff and the requirements of the carers legislation and indeed the sleepover rates as well those are discussions that have gone on with local government in order to to prioritise those elements within the overall local government allocation and you know we as we said earlier on have no reason to believe that local government is not going to deliver on those shared priorities why would they pay the living wage up to now and then not continue to pay the living wage when we know it is an important part of the recruitment and retention of social care staff so those are agreed priorities with local government I have no reason to believe that that's not going to be delivered I don't think Christine has either and we will continue to work with local government to make sure that that is the case can we just be clear what your pay policy is it goes beyond the living wage it includes a minimum 3 increase for public sector workers who earn 30 000 pounds or less a 2 increase for those between 30 000 80 000 so you've talked about the 66 million covers the living wage and sleepover shifts where is the funding coming from to cover the increase that will be on social care as a result of your other pay policy proposals well the funding coming from it's not contained within the 66 million local government have seen 135 million pounds cut in real terms in their budget at the very least they're getting a cash flat budget which includes areas now being ring fence for social care so where is the funding coming from to pay the increase in social care given the fact that the demand is increasing at the same time well the the pay policy is a government pay policy and that will be effective across government and will be paid for out of the allocations that have been given I mean we've laid out today our position on NHS and the how we will meet that commitment I've laid out to you today the support the additional support being given to local government in order to meet the living wage commitment but you know the general pay policy across the rest of the of government is laid out in the pay policy and that would be expected to be delivered in other sectors Christine is that just for clarification which I think maybe what you're asking for there isn't a specific funding stream for for pay awards in any of the sectors and there is no specific funding stream beyond the uplift to boards for the NHS until such times as we have clarity on on consequentials from the UK government so if that's a bit that you weren't clear about in the budget there isn't a specific line for for pay awards if there's a difference between what the pay review body awards and the policy is that going to be made up by government yeah I mean we've made the commitment but we know we would expect that you know if the treasury have made a commitment to deliver on a pay policy that the independent pay review body delivers then our input into the independent pay review body has obviously laid out our government's pay policy and the pay policy is a commitment that we have made and it would be disappointed if the treasury didn't make that commitment good and you know we would expect Scotland to receive its fair share of resources flowing from that commitment. I've had some indication of some of the discussions that have been taking place on a UK basis and there's nothing that would lead me to believe that that commitment isn't going to be made as things stand at the moment I would hasten to add so you know I would be confident as things stand that that the independent pay review body recommendation and what then flows from that will enable us to deliver on our pay policy commitment but you know if there is any shortfall of course we would make that up to make sure that what we have said and we're going to deliver is delivered but I'm confident that what we would see from the independent pay review body would would be in line with our pay policy. Okay Jenny. Thank you convener cabinet secretary in your opening remarks you mentioned Scotland's year of young people and it's obviously a huge focus for government this year but CAMHS waiting times continue to impact upon some of Scotland's most vulnerable people. The budget line projects a £17 million increase going into 2018-19 in terms of mental health services so how will you ensure that health boards use that funding directly to support child and adolescent mental health services if it's not ring-fenced within that budget line? So I mean as you've said that the 2018-19 budget has been increased by 17 million which is 32 per cent as part of the commitment to increase the mental health workforce by an extra 800 workers over the next five years and indeed for the transformation of CAMHS. The budget also includes £30 million as part of the existing commitment of £150 million on improvement and innovation in mental health services over five years and what we need to make sure and I think this is probably what your point is getting at that we need to make sure that that then follows through into the decisions that are made by boards and integration authorities. A lot of work is going on to make sure that that is the case so the ministerial strategic group that I referenced earlier on that we jointly chaired with COSLA has made the investment in mental health one of its key priorities and it is looking at how we ensure through some of the processes that Christine talked about earlier in terms of tracking where planned investment goes that mental health is visible and seen within those local budget setting processes. So I think it's fair to say that we have come to a collective view that it's not enough just to allocate the resources from Scottish Government and then assume and that those resources will always find their way to the front line in a way that we need them to see given that we have these very specific commitments to grow the workforce. So we will be doing things in a different way. Christine can elaborate a bit more but it has been very much identified as a priority of that strategic group and looking at making sure there's visibility to that spend in terms of the plan spend at a local level. The one additional thing that I would add to that is that in the funding letter with the draft budget we've said to the system that we expect there to be a real terms increase in the existing mental health spend to protect against and guard against any reductions in the existing spend as we put more money in and again through being able to report on a more regular basis we would look to see that. One of the things that I'd like to see confirmation on is that budgets are being approved for next year so that we're not waiting until a year after the event to make sure that that happens. I think that I would say that of all the budget areas for 18-19 it feels like the one that has been given most protection. I appreciate that. My concern as a Fife MSP is that there are five health boards as you'll know nationally who didn't meet that 18-week target. Will any of that funding then be directed at those health boards who weren't able to get there? Well there's also an improvement programme where boards that are not meeting the target are being worked with specifically through the improvement team and that has actually led some of the boards that are now meeting their target. It was through that improvement work that actually has helped them and investment but the improvement work as well so that they do things differently and work out what it is that they're either not doing or need to change where if there are staffing issues what are those and how do they address them. Work has very detailed work that is going on with individual boards to make those improvements and that would be the case for those remaining boards that have yet to meet the target. In terms of the spend and the work on CAMHS and other areas, how can we track that and what is being spent on and whether there are improvements being made? In terms of tracking the spend, if we're going to give you the consolidated information for integration authorities then it would have mental health clearly within that so I think that would be the easiest thing this week. The spend and the result of that spend? When you say the result of that spend do you mean in relation to particularly the target performance targets? I'm sure that we can put those together and give you regular information on that. It would be helpful to know how often you would want to receive that but I'm sure that we could do that. Anyone else, Alex, on this one? I'd like to follow up on Jenny Gilruth's line of questioning. If we accept that from the £17 million we'll have to find the 3% uplift for existing mental health workforce within the health service and then even though the 800 additional workers is over the next five years ultimately when we get to 800 that's going to be at least £20 million if not more a year. What of this £17 million will be left for CAMHS? What is the breakdown between what you expect to do in terms of meeting that 3% pay obligation for existing mental health staff for recruiting the first tranche of the 800 workers? What is then left for CAMHS? The 3% pay commitment won't come out of the mental health money. The pay commitment is the pay commitment. What I laid out earlier was the process for that in that we have resources within the NHS some of which have already been allocated around and boards have also some planning assumptions regarding pay but there is also the unknown quantity of what the independent pay review body will say and what the consequentials will flow from that. That is a separate funding stream. It won't come out of the £17 million. Sorry Cabinet Secretary, that's up to the discretion of the boards how they spend that money isn't it? To some extent but they won't be spending it on pay. Pay is a separate funding stream. The £17 million is an uplift for mental health services where we need to make sure that what happens next is that that resource has visibility in terms of what priorities it goes on and to make sure that as Christine reminded me we had set out in the letter that there was a requirement for a real terms spending increase in mental health. I think in recognition that sometimes the intentions of increased spend from Scottish Government don't always find their way through to the decisions that are made locally. I think we've accepted in the area of mental health that that was an area we needed to address which is why the letter says there has to be a real terms increase. In terms of what that money is then spent on I mean obviously there will be some within mental health some local discretion so if a board is already meeting its CAMHS target for example it may prioritise other areas of mental health spend for that allocation but where they're not meeting their CAMHS target we would expect that to be a priority for that spend so obviously we would expect boards to set out clearly to us what their priorities would be for that spend. We've asked for that as part of the plans that we would agree with boards for 18, 19 and the integration authority plans to be very specific about their plans on mental health but just for the violence of doubt we are seeing very clearly we expect existing spend to continue and to have a real terms, real terms 1.5 percent real terms increase and the additional 17 million on top of that so if we're fast forwarding a year from now I would expect you to be saying to us well have you seen that where's the evidence of that that's what we'll be keeping track of very closely over at for the start of the year and as we go through the year. Okay let me come at this from a slightly different angle which is of the 800 new workers how many are in place now and how many are going to be recruited in the next calendar financial year? Well that is part of the modelling going forward in terms of what the agreement with boards is and making sure we have definitions of who is included within those 800 staff so what is going on around that at the moment so that we can track and be able to tell you and the rest of the committee over the course of the rest of this parliament and establishing the baseline for that so that work is on going to make sure we've got the baseline because there are already staff that have been funded that are new that would come within the ambit of the type of workforce that we're trying to build but we want to establish what the clear baseline is in terms of measuring progress from here on and that work is on going. I don't have that to hand but I'm sure we can give you the time skills for the planned increase over the five-year period. We can provide you with that. And just to finish if I may because I go back to my original point that ultimately when we have these 800 new mental health workers in place they will cost at least £20 million a year so that's in addition to what we are spending on mental health right now if we're only talking about a £17 million uplift we're going to have to meet that with an additional uplift year on year in mental health is that the intention of this government? We see the growth in mental health spend continuing in order to meet that commitment and of course you know that's going to be you know you wouldn't expect that commitment to be able to be delivered in a one-year time frame it's going to take longer than that and therefore we the mental health spend in line would increase in order to provide the resources to deliver that. Thank you, convener. ISD figures regarding bank and agency staff show that last year £142 million was spent in 2016-17 that was up from 134.5. Similar to what I had asked earlier on in regard to obviously mental health funding and its budget etc but it's how that budget is spent as far as I think we're all concerned how it works out and I just wanted to be a bit of clarification you mentioned in the papers we have we mentioned community health service budget and I'd already raised the fact about community health service and you're going to come back with a paper in March so I think it's important that the way we get to the nub of the situation where we have the extra money going into community health but there's a partnership aspect of it also so I'd just like to be a bit of clarification when you produce the paper in March in regard to community health services will that have some of the mental health budget how it's spent in there because we had the great you know yahoo when Margaret Thatcher was there about community health and people were just flung out with no money to support them so I think it's important we look at the basics of where the money is spent so will that be coming in in any report you give in March about the mental health budget i under the community aspect as well because a lot of the work is carried out in the community most of it rather than the hospitals so part of the way we see the shift in spend is through mental health so yes we would expect it to be part of it so but I mean if if you are asking for maybe more detailed information about mental health then that might be something we should do as a one-off for you to understand not just the bottom line but how it's being spent because that's information we would need to to collect what I'm aiming to do in that first report is tell you the total amount on different components rather than how it's spent so if you really if it's really how it's spent then we would probably the best thing to do was to do a more detailed analysis for you and provide that the position I'm taking can be just a small one is there's so many various areas within mental health integration and social care local government has a lot to do with it as well you know so I'm good in my opinion anyway to see exactly how it's spent on the ground and how it does the money does benefit the people who are really needing it basically I agree and it's one of those areas where it's relatively straightforward to get the direct spend on it but be able to identify all of these other areas can take a bit more time so but I think if everyone agrees that it's an area that we need to that would be worth doing it then we could certainly commission that we'll make contact regarding that and so you want to follow up on the alcohol and drugs partnership. Thank you. Good morning. I'll try and go through it as quickly as possible. Thank you very much for obviously in your introduction remarks about the 20 million pounds which is additional for alcohol and drug partnerships however having looked at the evidence basically although it will increase we don't really know how it will be distributed to health boards or whether it will be distributed to health boards and it's not clear to this committee with the figures we've had the current level of spending on alcohol and drug services it doesn't seem to be it is recorded and the government records it but the transparency isn't there for the committee or anyone else and I just wonder if you would agree the fact that the lack of the transparency makes it very difficult for us to see how much of the budget is there and whether the Scottish Government would agree to publishing the information that they have on ADP budgets. So we'll certainly look to see what further information can be published to be as helpful as possible it should add obviously that that 20 million is in addition to the funding that already goes to boards baseline funding and actually boards and partnerships spend an awful lot more money on alcohol and drug spend than than the 20 million so it would probably be helpful for us to be set out in a follow-up that additional spend that goes in because that's the vast majority of it. In terms of the 20 million we are in discussions with boards and partnerships at the moment about the priorities for that spend because we would like to ensure that as well as what ADPs do in terms of their day-to-day delivery of services that there is an element of that fund for transformation and creation of new services and meeting unmet needs and really trying to make sure with the delivery of the refreshed substance misuse framework that there's resources that can help to deliver some of those priorities that are going to emerge from that so it is a balance of making sure that the resources are providing for services in the here and now but also that there's an element for the development of new services but we can follow up with some further detail if you'd find that helpful. Just a very small thank you very much for that because we do need transparency and this comes from the fact that actually SPICE had to put in an FOI to get some information which obviously from my committee point of view you know isn't so great that's why I was asking we know that the government keeps has information we would be able to provide it and I quite understand that it's not quite as simple as just one budget that goes there and that's where it's spent it's all different ones and it's just obviously the minutiae of it to try and get to the nub of it. Something that comes back to that earlier point that the funding transferred to board baselines so we don't in previous years it was a budget that we held so we could very easily tell you what the total budget was when we transfer it to the system and you leave it to local determination then unless you have a mechanism to get a consolidated report then it's either we go out and ask everyone what they're spending or you have an FOI so I don't believe that there's any withholding of information going on I think it's just that we're dealing with funding in a different way so I'm trying to avoid this consolidated report being the answer to everything but I think it will give you a much better overview of the position because if I look at any integration authorities published trans reports I can see substance misuse or an equivalent title in them so there is a level of local transparency on the spend but there isn't is right now an easy way to pull all that together and give you a single position across the country and that's what you're asking for and that's what we're saying that we'll start to pull together so we can certainly do that the way in which the £20 million will be invested will come through the refreshed frameworks so there'll be a bit of a time delay before we can give you the full information on that that's fine thank you the significant number of the committee members were very unhappy about what happened with alcohol and drugs partnership budget now we see 20 million in back and it's actually only an eight increase of four million if you take account of last year's reductions but the reality is that we've got the worst drug deaths rate in Europe we have a drugs disaster on our hands in terms of deaths from drugs is this anywhere near enough to start to really tackle what is a real public health crisis in on the streets where people are dying? Aileen Campbell in her statement laid out that there was going to be a renewed focus on those drug users who have perhaps been using drugs for many many years they're getting older they have a multitude of different chronic health conditions and it's almost like I think it was like a seek and treat that there was going to be a focus on actually really trying to proactively engage with that community because that is the area where those drug deaths were emerging from so a really very much a refreshed approach focusing on the individuals concerned to try and engage them with services to to address the very point that you're making convener so it is a different approach I think Aileen Campbell laid out in some detail why it is different and how it will be different and you know the resources new resources will will be aligned to those that refocused commitments we are dealing with a generation of drug users who you know are now you know in their their later years and that brings with it a bit a challenge to and many of them don't engage with with services in a way that we would like so a lot of work is is being done to try and look at new ways of doing that and to look at how to address some of their health needs also should say a lot of work going on between ourselves and justice department to around the prison population so that when people are coming out of prison that they are better supported particularly around issues of alcohol and drugs and I think that is going to help to possibly provide a better support system for for people who are at that vulnerable position. I may follow that up personally and write to you about that because there's a whole new generation of young people coming through who are experiencing drugs particularly cocaine in the streets are awash with it and that's not the older generation that we've known about for some time this is a whole new generation that grave concerns about but anyway a bit short of time on that I'll write to you about that. Okay, that's fine. Who's next? Brian? The panel is part of the committee's call for evidence in relation to the pre-budget scrutiny. We received quite a few written submissions from a number of sports bodies raising concerns about the transparency in relation to the sports budget. The suggestion is that more detail on the sports legacy physical activity budgets would support that better scrutiny so with that in mind can I ask what the reasons were to change to include the sports budget within the overall health budget and whether you actually agree with the comments regarding the lack of transparency in the sports budget lines and what action you could perhaps take to address this? Well I mean we're happy to provide as much detail as possible. I mean I think the rationale for trying to better integrate the sports budget into the health budget was really because of the I guess the dimension of trying to look at physical activity and active living as part of the health response rather than it's sitting somewhere else and therefore you know the the budget that is is allocated to not just sport scotland but in terms of the active programme is really tried to do some of the prevention work and actually sport scotland themselves have done a lot over the years to change their focus so they're doing more around looking at programmes that support children and young people to be active rather than it being necessarily about specific sports so I should point out that sports Scotland's budget is going to increase by £2 million to £31.7 million and that is to deliver the services that they deliver and also to look at what more can be done. We are also as I said in my opening remarks underwriting a fall in national lottery income for sport scotland of up to £3.4 million because I know that there was a lot of concern from sports bodies around the fall in income from the national lottery and we would hope that the UK Government will be looking at how it addresses those concerns. The active healthy lives line is a new budget for 2018-19 and looks at trying to ensure that we are doing the right things particularly early intervention and I'm happy to provide more detail on that if you'd find it helpful. Just for clarification the extra £2 million that's coming into the sport scotland budget brings it back up to the level that it was at two years ago given that it was cut. The budget was cut a couple of times and I think that for me the transparency around sports delivery is predominantly done through councils as well. I wonder what links you have with the programmes that sports scotland are delivering with the increased financial burden that's going on to councils just now to deliver those kinds of programmes. Of course local government remains a key deliverer of sport and obviously the decision to continue business rates relief for sport and leisure centres will help to make sure that the good work that's going on within local authorities continues. There are sports scotland work very closely with local authorities as I'm sure you're aware in developing plans to deliver more active programmes. A lot of work within schools for example that sport scotland are involved in particularly around making sure that before, during and after school programmes are delivered as well as supporting the commitment to physical education and having a minimum delivery of that. All of this is within a context of a budget that is increasing due to the tax decisions that we have made. If those tax decisions were made differently then there would be even less money for local government and the NHS so these are political decisions that each and every one of us around this table has to make when we're deciding what resources should be allocated to any part of the public sector. Just for clarification I want to understand what your understanding is of the money that sports scotland have, what their spend should be on as compared to what the lottery funding spend is allocated for. Is there a different allocation? There will be, the national lottery allocation will be to meet the requirements of the national lottery in terms of what the programmes are that they've agreed to fund so sports scotland will have different funding lines for different programmes depending on what funding stream is funding which which you know is not an easy thing for them if they're relying on different funding streams which is why it was important to underwrite the fall in national lottery income because it gives a bit of of breathing space for sport scotland to look at the programmes that they're running while discussions are on going obviously with the UK government around national lottery resources so you know I think they I'm not saying it's an easy task but there is something that they require to do in terms of the the relative programmes and how they are resourced. Just just finally if I can ask is the sports scotland allocation does that incorporate a capital spend? The capital spend to sport scotland is the source I think but we could come back and just be sure about that. I think the capital is now is now concluded but I can check that for you. We'll come back and clarify that. Thank you and I think we've come back full circle to talk about performance and outcomes. I haven't spent an hour and a half talking about the inputs and that suggests how far we've got to come in terms of where the narrative general is when we talk about the performance of the portfolio. As I said at the start, to my mind it's critically important that we focus on the outcomes and I think everybody agrees with that and also the relationship between that and indicators and targets. I don't want to go into that too much just now because we're going to come on and talk about that in the next session about the Harry Burns report but what I would say is that certainly echoing what Harry Burns said, the landscape to me does look confusing. You've got the national performance framework indicators, you've got local development plans, you've got the integration indicators all kind of cut across each other. The budget report along with that comes in assessment against 25 indicators in there that are health related allegedly but when you look through a whole bunch of them, to my mind the impact that the health budget can impact on those is minimal to zero so I'm not quite sure why they're in there. I suppose that there is a question round about do you think we're measuring the right things even at that macro level and how effective is what's in the budget report in terms of what we're focused on and then drilling down to the indicators that are there of the 25, those four where allegedly you're missing or you're missing or the performance is worsening, let's put it that way, because there are no targets. It's the performance is worsening against previous years. Of those four, I'm looking at them in two of them, I'm saying I don't know why they're in there, one of them is road deaths and one of them is poverty, which frankly the impact, unless you correct me if I'm wrong, with the impact that you can have on as the health budget on those is how to suggest minimal. The two that are missing are alcohol related admissions and the percentage of adults assessing their health as good or very good. Now if we were to take it at face value and this was a robust performance measurement system, notwithstanding everything that's been said in the last year and a half, you would say that those are the only two areas where the health portfolio is falling down. Now I think that we probably all agree that that's probably not the case, which to my mind can I suggest that there are major weaknesses in the way that this is set up in what we measure, but I'd just like to get your reflection on that. A, in terms of is the system doing what it should do, in terms of measuring stuff, and B, on those two specifics, if you get any comments? Yeah, I think that laid out like that. I think that we make a fair point that sometimes we may overcomplicate matters and we have all the outcomes that on the national performance framework. I think that we should have a look at that, because in terms of the day-to-day priority, in terms of outcomes, I really have shifted very much towards the integrated agenda. The focus is on preventing admission to hospital, reducing unschedule care, tackling delayed discharge, looking at some of the early years work around reducing some of the, you know, making progress around the indicators in terms of early years progress with the health visitor programme and so on and so forth. So really in terms of what we think about of the performance and where we focus our attention, it's probably a bit of a mismatch in terms of those overall. So I think it's probably something that we need to think about as we take the national performance framework forward. I would just say, though, in terms of what it indicates, as you mentioned, about poverty. I've always said that the health service in itself has a big contribution to make towards tackling poverty, but it can't do it of its own. Tackling inequality and health inequalities can't be done by the health service alone, but it does have a contribution to make. So if you look at the role of health visitors in the early years, the family nurse partnership, the making sure that children get the best start in life, all of those inputs should be important in having better outcomes for those children and we have a focus on that. So I think we should take away what you've said and have a look at with our colleagues in government, across government, around the national performance framework and whether or not those are really a reflection of where we are with the priorities that are set on a day-to-day basis for the health service. So we'll take that and have a look at it. My question was regarding agency and bank staff and looking at the ISD figures that were published, it showed that £142 million was spent in 2016-17. That was up from £134.5 million. I raised this question this time last year and both the cabinet secretary and Ms McLaughlin said that overall you're expected to see a minimum 25% reduction this year in agency staff costs. So my question is really what's gone wrong over the last year and why are we seeing it increasing further? Well first of all I'm glad you've given me the opportunity to highlight a number of things around this in the context of the budget. So first of all it's important to say that nurse agency spend is about 0.4% of the total budget. It is very small indeed and we have to be clear of the difference between bank and agency nurse. Bank nurses are NHS nurses who are doing extra shifts through the bank as opposed to an agency which is obviously taking an element of funding for its services and all of the issues that that raises. What we are doing around it is we have increased in terms of the budget for this year an increase of £16.7 million in respect of the projected increase in student intakes for 2018-19 on the student nursing and midwifery pre-registration fees and bursary budgets because of course we've kept the bursary here in Scotland to enable us to deliver the 2600 additional nursing and midwifery training places over the course of this Parliament. The reason that's important is because it will lead to a very substantial increase in the nursing and midwifery workforce which will in itself help to reduce agency spend. So there has indeed been a reduction in the agency spend over the course of this year. Christine can say a bit more about that. So we are seeing reductions in agency spend. We've been working with boards very clearly indeed to reduce that agency spend and we're also increasing the medical workforce through the programmes that have been laid out in the medical education package again in this budget £4.2 million being allocated to expand medical education. All of that is about building our workforce both in nursing, midwifery and medics to ensure that we are able to not just reduce agency spend but we're also able to mitigate against the impact of Brexit for example and the impact that that is likely to have over the next few years. So you know in terms of the budget there is a substantial injection of resource into this area to make sure that we reduce our reliance on agency spend. Very over time so I want to try and... Well we could write with a follow-up if that would be helpful and we're on this detail over that. Is that okay Miles? Brian, on Brexit, very, very briefly. I appreciate your short time, convener, in regards to Brexit. I just wondered how the cabinet secretary is inputting into the discussions on the implications of health in social care in Scotland, whether your officials have been or will be involved in those negotiations. What methodology you'll be employing to hear the views of the sectors affected and how you propose to keep this committee updated? Well, Brexit, as I've said here before, is a major concern for not just NHS but care, the care sector as well. We are inputting into obviously Scottish Government discussions and you'll have Mike Russell and I meet regularly in terms of the intelligence within NHS and care services. I meet also regularly with stakeholders in order to get feedback from them directly. For example, the BMA have done a lot of work around their own stakeholders in terms of giving us that information. I met recently with Scottish Care and was discussing with Donald McCaskill some of the pressures on the here and now, so he was able to tell me, for example, that the recruitment agencies that operate across Europe that provide nurses for nursing homes here have essentially closed their doors in Europe because nobody was coming through the doors and that they are feeling an impact in the here and now in their nursing homes because of that. There are things happening in the here and now that are not just about looking to the future. We are looking, for example, of trialling a programme in Dumfries and Galloway where NHS nurses will provide a locality-based response to the nursing needs of nursing homes. There obviously have to be a contractual element to that, but that is us trying, working with Scottish Care, to provide a practical and tangible solution to the fact that nursing homes are not going to be able to recruit nurses for all of the reasons that we have set out. We are very much involved in those discussions, very much involved in providing the intelligence, but also, importantly, very much involved in providing mitigation against what is going to be a very, very, very difficult impact for the NHS and our care services. How, then, do you propose to keep the committee? Well, I'm very happy to write to the committee on a regular basis as information emerges. It's a fluid situation, as you know, and negotiations are very fluid. At times where we have something substantial to tell the committee, I'm happy to write to you with that. Okay, thanks very much for your evidence. I'm obviously staying on for the next session, so we'll suspend briefly to change the panel. Okay. The second item on our agenda is an evidence session on the review into targets and indicators in health and social care in Scotland. This follows our evidence session on 5 December with Sir Harry Burns, who conducted his review. I welcome to the committee Shona Robison, cabinet secretary for health and sport, Jeff Huggins, director for health and social care integration and Dr Catherine Calderwood, chief medical officer, Scottish Government cabinet secretary, who would you like to make your opening statement? Thank you, convener. I'll be as as quick as I can. I welcome the committee's interest in the review of targets and indicators and I'd like to acknowledge the considerable work by Sir Harry in undertaking the review and the contributions from members of the expert group. Committee members will recognise the importance of our commitment to ensure that we have targets and indicators that are fit for purpose, which reflect our current priorities and which lead to the best outcomes for people. We recognise that much has changed over the last decade in our approach to health and social care. Our vision is of a Scotland where people live longer, healthier lives at home or in a homely setting, where services are integrated around the needs of the individual and focused on prevention, early intervention and self-management. Our health and social care delivery plan was published over a year ago and sets out some of the actions for achieving that. It's essential that our targets and indicators are fully aligned with our work to realise that vision. I welcome Sir Harry's report and the principles that it outlines. I know that, like you, we particularly welcome Sir Harry's emphasis on equality of opportunity for everyone in society, enabling people to be resilient and in control of their lives and I'm pleased that Sir Harry recognises that Scotland has highly challenging targets for public services, which have driven significant improvements in many aspects of health and social care. Within the NHS, Sir Harry recognises that our targets have transformed waiting times for patients and have improved safety. Timely and appropriate access to treatment is important and I've already announced that our current targets such as cancer treatment, A&E and the treatment time guarantee will remain, but Sir Harry was right that we should seek to understand performance across a whole journey of care rather than focus on individual targets or indicators and I'm pleased that he acknowledged the progress of integration authorities in adopting such an approach. This has led to better understanding, for example, of why patients are presenting at A&E in the first place and the provision of alternative community-based services to better meet people's needs. I'm mindful of the demand for emergency care services, which has been unprecedented over the festive period. We know that this is down to a number of factors including surgeon falls and fractures, as well as people presenting with flu-like symptoms. Such exceptional circumstances mean that some patients stay longer than four hours in our emergency departments, not simply because of the pressure on the service but also because that can often be the right clinical setting for assessing their needs and deciding on the most appropriate treatment. NHS boards have responded to the demand to ensure the continued delivery of safe and effective patient care. We are working closely with boards to support them through the winter. In summary, we agree with Sir Harry that further work on our targets and indicators is required and we are going to take that forward to create a more balanced approach with a broader-based assessment on the quality of care. That needs to take account of people's wider experiences of care and I am committed now to take that work forward with COSLA and other partners. I welcome the committee's contribution to that. Okay, thank you very much. Ivan, will you like to begin? Yeah, thanks, convener, and welcome back. I suppose that following on from where we kind of left off in the last session, would I look at this debate within the health service and reflect on my experience of running these kind of systems in a previous life? I often find it a bit disparating that there seems to be kind of two camps set up. There is a kind of outcomes camp, and there is the targets camp, and they kind of just lob hindren as each other. I think that the Harry Burns report goes some ways towards understanding and recognising that, frankly, all of those things are part of the same thing. You need to know where you want to go to, what you are trying to deliver, what your outcomes are going to be, then you need indicators to measure whether you are getting there, and then you need targets to assess how you are progressing. Those things absolutely need to be co-ordinated together, and people suggest that, otherwise, frankly, they do not understand what we are trying to do here. I am glad that it is moving in the right direction. The issue then, of course, is that the hard bit is figuring out what you are going to measure because it is very easy to come back and see unintended consequences because of XYZ, but, frankly, that is because the design of the target system was not correct in the first place in your measure of the wrong stuff, and that is why a lot of thought and a lot of hard work needs to go at that level. It is clear from the outcome of the report that there is a long way to go still to make sure that that system is robust. I suppose that the questions that I wanted to touch on were, do you recognise that, at the moment, the environment that we have got with multiple different indicators, which overlap with each other, is cluttered and confusing and needs some clarity? I suppose that the next question is, where do you think that we will go next in terms of the work that Harry Burr has done and where does that go? I think that what I would want to see from the next phase of the work is to look at that landscape and to bring more of a coherence to it. So, if you take the A&E target, for example, the reason that it is important as a target in itself is not just because of how long people wait in A&E to be seen treated and discharged, it is used as a bit of a barometer of how the whole hospital is performing. So, if I was a member of the Royal College of Emergency Medicine sitting here, I would be saying that, for them, it is important because it enables all of their colleagues in the whole hospital to take responsibility for what is happening at the front door of the hospital. However, what we have done with the integration authorities, and this is getting into the territory that you are talking about here, is actually we have taken a step before that. The indicators that the integrated authorities are looking at is how do you reduce demand on unscheduled care in the first place to avoid people ending up in A&E who do not need to be in A&E by developing those services locally. So, it is about joining the dots on that. Jeff can say a little bit more on this area, but it has been really quite groundbreaking to have the chief officers and the chief execs of councils as concerned about how do you reduce demand on unscheduled care as a chief exec of the health board for the first time. So, they see it as as much their responsibility to reduce that demand on unscheduled care as the NHS does. So, that gets us into the right space. It is then about how do you make that whole process transparent? How do you keep the importance of what happens at the front door of the hospital, but you take the whole journey from what happens in the community through to someone either being admitted to hospital or discharged from A&E. So, that is a bit we want to do more work on to really measure the outcomes and how successful we are going to be at keeping people away from the front door of the hospital when they need to be there. So, I think that the work that we have been doing with integration authorities in that area has been really interesting. We are about a year into that. It was about this time last year in the context of the previous spending review that we wrote to integration authorities to set out the six areas where we were looking to, for them to set their own objectives and to make progress. I think that Sir Harry's review learned quite a lot from that process because if you look at the five of those indicators, or indeed all six of them, they are unscheduled care bed days. They are attendances and four-hour A&E performance. They are delayed discharge. They are the availability of palliative and end-of-life care. So, you are looking within that at a number of different dimensions which are all about the whole journey rather than about particular points on the journey. The process has been interesting because when we then look at what happened within local systems and the objective setting, we see probably four different dimensions to what was going on. As the committee will know from the evidence that we have offered before, most integration authorities have got very different starting positions. So, targets generally impose a level at which everybody must be. Our experience with that is for many of the targets. Some areas will achieve those targets relatively easily, but other areas will really struggle to achieve the targets. Where our overall interest is improvement. You see integration authorities looking at different starting points. You see them having different levels of ambition. That has been quite interesting. Some expect to make more progress over 12 months, others expect to make less. They have different degrees of capability and support to take forward change. Some of them also have different understandings as to how the world works. What is the impact of demography over time? All of those things come together in how they present our objectives for the next 12 months. We have been working with the chief officers so that they can see what each other is doing to offer a degree of moderation through the process. In the context of them using that to think about what their plans would be in place to take forward the change that gives them the improved services at a system level that they are looking to achieve. That work is a very good trailblazer for the approach that Sir Harry is looking for in the future. He looks at systems of care and the degree to which they function effectively to produce better quality. He understands the interactions between different services. Early in Harry's report, one of the things that he identifies with targets is the challenge about how they pull the focus very sharply into one component of the system, at times potentially at the risk of other parts of the system. His exhortation to us is to think more broadly. I think that the integration work has been very helpful in that space. It is good to hear that. There are a couple of points out there. You are absolutely right at the systems level. That is obviously where you need to start. System level indicators need to be aligned to what your outcome is for the whole health system. Clearly, there is a hierarchy below that. I suppose that is a bit of a mess. There is a lot of stuff thrown in there, but it is not clear how it relates to each other, because you will have a measure for the whole system, but individual parts of the system will have their own subindicators that will feed into that through that hierarchy. The other point is about targets. There is absolutely no reason why you would not have different targets for different integration authorities. The important thing is that the framework is the same, and they are measuring the same stuff. It is clearly depending on where they are on the journey that they will have different targets. That is good to hear. Good morning to the panel. I think that what I was struck when, by most, when Sir Harry came to talk to the committee was by what was not being measured rather than what was being measured. As we know, the old adage says that what gets measured gets done. He specifically used a lot of his time to talk about the fact that we need to be collecting more information about adverse childhood experiences, because trauma in childhood leads to some of the most negative social outcomes that we have, and there is a lot of research to that. Can I ask what the Government's response to that will be, and whether it now intends to start collecting that data and then approaching service delivery from a more trauma-informed response? I think that there is a lot of importance, obviously, in what Sir Harry says around that area. If you track those who have had an adverse childhood experience, have suffered trauma in childhood and you marry that up with the prison population, with offending generally, drug and alcohol dependence and so on and so forth, it is there very, very clearly for all to see. If there can be an interruption to that through the collective efforts of services and Government, that is obviously something that is very, very important. We have had a number of cross-Government discussions about that, looking at how, for example, we can work more closely with our early-year services, work more closely with education to find those opportunities to interrupt. The work of health visitors, the increase in the workforce there is important in this territory, the family nurse partnership, the attainment fund within schools, the work that we are doing between health and justice to look at how we can get better intelligence of what has happened in people's lives and what would have helped at particular times to interrupt that cycle. This is something that the whole of Government is very keen to do. I guess what we would want to work out through the next phase of this is what might that look like in terms of—it is not an easy thing to measure—how do you measure what worked in someone's life when that made the difference between a good outcome and a not-so-good outcome? We need to put some thought into that, but please be assured that it has been recognised as something that we think we can do more about in a more systematic way than we are at the moment. I agree the intent is there, absolutely. I am not really talking about measuring what worked, although that is a very important part of it. I think we need to get the basics right, and that is what Sir Harry was talking about, particularly around just capturing the traumatic life events that children experience. That is not just the usual what we would expect as traumatic life events such as bereavement and loss, but things such as attachment disorder and the experience of disruptive homes, abusive homes and the rest of it. The NSPCC producer report called Right to Recovery, which suggested that a very small proportion of Scottish local authorities have trauma recovery services, dedicated trauma recovery services. What Sir Harry was alluding to was the fact that we are not getting the business end of this. Whilst there is a role for health visitors and the pupil attainment fund and the rest of it in mitigating the impact of childhood trauma, we are not addressing the absolute sharpest end of this in terms of trauma recovery. I do not think that we will address that until we start capturing those basic statistics. Is there a commitment from the Scottish Government to answer that challenge from Sir Harry and start recording the reasons for that trauma, not just what we are hoping to do about it in the future? I am going to make it up to you. We need to be really brief and sharp with both answers and questions, okay? Yes, lessons there is. Catherine, do you want to say? We need to learn, I think, from what they have done in Wales. There was a 2016 study in Wales that looked at adverse childhood experiences. 47 per cent of the Welsh adult population have had one adverse childhood experience and 14 per cent have had four or more. I think that when they got those data, they were surprised as a country as to just the prevalence. So we are going to add into the Scottish household survey that you will be familiar with, some questions, and this is initially in adults on adverse childhood experiences. What we do need to be aware of, and Mark Bellis, who wrote that report in Wales, and I have had discussion about this, is that some of the revealing of the past experience is actually traumatic for people. In fact, we need to be very careful about how we phrase the questions and also be prepared for people needing to come forward to have help, even because they are recognising that perhaps the outcome they have ended up with has been because of their childhood and that link has not been made for them before. What we would also want to do is work with the ACE's hub, which has been set up. Linda DeCastiker, director of public health in Glasgow, chairs that hub. What we are talking with her about is having some form of routine inquiry for every interaction with health and social care. Again, that would need to be done very sensitively, but what we would be doing would be putting in where, from my point of view, there would be a medical history taken and there would also be some inquiry as to the child's background and the potential for adverse childhood experiences. It is much more difficult to ask for children who are then in that situation at the time, but obviously extremely important because you can then act and prevent. We need the data. I think that you are absolutely right that we do not have that for Scotland. I would say that it is unlikely to be very different than the Welsh experience. We need the baseline data, so we are intended to collect that. We do have the ACE's hub with a lot of ideas already about how we need to take forward work in Scotland. Just as a follow-up to Alex Cole-Hamilton's line of questioning with regard to ACE's, Harry Burns is quite critical of GERFIC. He said that well-meaning policies such as GERFIC have arrived, but it is time that someone came up with a system to create success at school and pulled all of that together. With regard to that agenda, do you agree that there is a disconnect between health and education at the moment? Could we be doing more? I think that we can always be doing more and there have been a number of discussions taking place about what that more can be in a more joined-up way, looking at the support of women before they give birth through to early years through then to school and looking at how we make sure that there is more of a coherence in opportunities to support families. We have done a lot of work in that early years zone, so the work around the expansion of health visitors, workforce, family and nurse partnership, trying to support families in those early formative years in order to deal with issues such as attachment issues, those family struggling at that time and really trying to have a positive impact before the child enters the school environment and then within the school environment trying to pick up and early stage any issues. There is always more that we can do. Catherine and colleagues are looking at how we can more closely join the dots across government, particularly between education, health and justice. One of the recommendations from the report is that analysis of school attainment rates should routinely consider the effective adverse circumstances arising from socioeconomic deprivation on attainment. Cabinet Secretary, have you had any specific meetings or discussions with the Cabinet Secretary for Education on that recommendation or do you plan to in the future? Yes, we have had a number of discussions about it and also the whole area of how we have just been talking about how we can more closely align the collective resources that we have to better support those children who need that support in a more systematic way. We have had a number of discussions around that and the wider issue. What we need to do and I think that Sir Harry's challenge to us provides a format for us to look at how we measure that. How do we measure what the impact is of what we are doing at the moment and what new services and new supports that could be developed? The other thing to recognise is that this is going on in parallel with the work on the national performance framework, which looks across all of government. Some elements that have appeared in Harry's report are likely to end up as part of that process in taking a more overarching approach, whereas some elements from his report will be more about the health and care system. Brian Whittle, I will look at the role of targets and indicators. In the committee, we asked in several sessions here what a fairly straightforward question was about who monitors one of the indicators, which would be a significant adverse event. From my understanding, we get nothing but waffle. From Jason Leitch, he has written evidence that seems to contradict his oral evidence. It is really quite simple. We just asked what constitutes a significant adverse event. Is it universal across health boards and who monitors them at a Government level? More importantly, are there any significant changes within an adverse event's numbers within a health board? That is obviously important, because if there is a significant change, there are either instigated practices that should be rolled out across the whole of our NHS, or they have changed the way that they record them. If nobody at Government levels watches that, how can we learn from those targets? What Catherine was saying earlier is that there is work and improvement to be done in that area of creating, first of all, knowing what the figures are and trying to get a proper analysis in looking at what they have done in Wales in terms of what the impact of the population is, and then to create, I guess, a bit of a baseline to be able to then look at, well, how do you interrupt that in an effective way? I take your point. I think there needs to be more coherence. I think the work emanating out of this and the work we are doing jointly across Government can set a far clearer framework for an ambition. It is a very ambitious thing to say that you are going to really aim and seek to tackle adverse childhood events in a systematic way, and how you do that is very difficult indeed. However, I am very happy to, once the work is under way more fully to come back to the committee on that specifically to set out how we are going to do that and how we are going to make sure that the monitoring and oversight of that is robust as it needs to be. Were you intention, then, to put that in the public forum? So the sort of changes or any measurement of those within the public forum? Yeah, I mean, we've got work to do, I think, in terms of what we're going to measure, how and baselines and how we're going to take that work forward. So it's a pretty early stage, but once that has been pulled together into the plan, then, yeah, I'm very happy to share that with the committee. Thank you. Okay, Brian. Colin? Thanks so much for giving up. Can I just go back to? I think that the crux of the whole review, and that's really the big challenges that we face, the fact that, of the 16 Western European countries mentioned Scotland's got the lowest life expectancy, the inequality gaps increasing with affluent Scots living the life expectancy rising and those in deprived areas actually falling, but obviously those inequalities are complex. In the current thinking on transformational change for wellbeing suggests adopting this whole life course approach across the whole of government focusing on social justice, growth and wealth. So you effectively have this one system of indicators on health and wellbeing, but that cuts across every government department. Is the life course approach something that you support and how, from a practical point of view, do you actually deliver that when we still work very much in silos across departments? Yeah, I think there is huge merit in adopting a whole life course look at the way we, what our priorities are, how we measure what those outcomes are in a more systematic way. I mean, there's been some progress made across government in trying to, what you've described, is break down the silos, and when you look at, well, for example, the integration agenda, I think that shows that where silos are genuinely broken down, then there is a responsibility taken that was previously not seen as someone's responsibility to be blunt, and what we need is to see the, you know, improving the life chances of our next generation of children as everybody's responsibility, and to do that in a joined up coherent way. There's been a lot of work done around that. I think we need to pull it together more fully, and the direction and challenge that Sir Harry has given us, I think, will provide further impetus for us to do that. I think, though you identify that it's not an easy thing to do, and it can be interrupted by things that sometimes appear out with or can be out with our control. So, you know, without being, you know, to find a point on it if, for example, the welfare reform agenda removes the income of a family or reduces the income of a family that then impacts on the poverty level that that family is facing, and therefore all of the things that flow from that. That is quite a difficult piece of the jigsaw to then have as part of our plan, because it is not something other than mitigating that as far as we can, and we have obviously put a lot of work in place to try and do that. So, you know, I think we need to absolutely look at how we can, with all the levers at our disposal, do more and better around this, but I think that we also have to recognise that sometimes there are impacts that are out with our control that do have a pretty severe impact on household income, employment and so on and so forth. I think that the other thing that is quite important from the review is also how Sir Harry widens the scope of the things that we consider when we look around outcomes and indicators. At the moment, we are doing work in Dumfries and Galloway around dementia outcomes and indicators based on work that we have done with the international consortium on health outcome measures. What they are looking at is being able to measure across systems things like people's sense of control, their social connectedness and those things that are really quite fundamental to broader health and wellbeing outcomes, but we are finding that to be really quite challenging because those are not the traditional sorts of things that we have measured in that we tend to measure things in very particular situations, which are time-binded and which you can put into a spreadsheet quite easily. Whereas at this stage, when you are looking at the quality of experience that people have, which also affects the likelihood that they might present at A&E or go to their GP for support, what you are beginning to look at is a lot more granularity within local systems to understand how well we are supporting people to live the lives that they want to live. That is largely an undeveloped area in our system and, indeed, in systems across the world to be asking those questions. We have had the conversation on more than one occasion about issues to do with loneliness and the degree to which people have good social ties and support systems around them. Those that are not part of our measurement system, although those can be as important or more important than individual clinical interventions, that is quite challenging. The other element as well is that it begins to enable you to step into the space of realistic medicine in a different way and understand how not doing something might in some occasions produce a better outcome than doing something. At the moment, all the things that we measure in our system are where something has happened, but we do not have a methodology to understand what the impact of something not happening was. Once you begin to look at those qualitative factors and bring them into the story, you can understand and perhaps help people more to understand what they might want in terms of other people's experience. There is really quite a big challenge around the way in which Sir Harry has opened up the space of looking at indicators and outcomes beyond the very traditional understanding of how fast or how well a system is operating. Ultimately, measure is going to be the big challenge. Specifically, Sir Harry goes on to say when he talks about the life course approach that individuals need support at different key stages, pre-birth, early childhood, and he argues specifically about the fact that the early years support is obviously key. I am going back to the point that Jenny Medellar is a scope to reinvigorate the work of the early years collaborative in light of what Sir Harry is saying in the report. I think that we need to look at all of the mechanisms that we can use and the levers and the expertise that we have, not just in Government and partners, but with the public as well in terms of those who have been through many of these experiences directly. I think that there is something in that. The early years collaborative has done a lot of very good work. We need to do those to take a step back from that, first of all, and to reassess what it is that we want to achieve. What are the outcomes that we want to achieve and how, across Government, we are going to do that and whether or not the mechanisms, the collaboratives, the methodology that we have for delivery of that, whether it is fit for purpose or whether we need to do something different. We are at the stage of looking quite openly at where we are at and, with a commitment across Government, to refocus and re-energise work around this area. I am very happy to keep the committee informed about that. Sandra White and Emma White want to come in on this issue. It is about the lifestyle approach that Sir Harry's papers are absolutely spot on. It is about holistic collaborative working, but the one that I wanted to pick up on—you mentioned yourself, Mr Huggins, about loneliness and so on—are we taking any of the data that we get from the deep end practices? The deep end practices are targeted to the most disadvantaged areas in Scotland and the people there. They have shown up some issues where people will turn up older people in particular, and it is just loneliness. It is not necessarily that they need any prescription or see a doctor. Has data been taken from that that we can use in this lifestyle approach? Yes, but also the new GP contract will enable us to get a far richer seam of data coming through primary care in terms of what is measured and what we then know about the population served by that GP practice in a way that we have never been able to do so before. That will help not just the GP practice and its partners to look at the services that need to be delivered to that area, but it will help us collectively to look at what the needs are of that population. In terms of a more deep end practice or services being delivered to more deprived communities, that will be a rich seam of information that will tell us far more than we know at the moment in a more detailed local way. That provides us with an opportunity to drill down and not just to look at the data but to formulate service delivery and support around what that data tells us. There are perhaps two or three things to build on what the cabinet secretary has said. The report suggests that, as part of the work to take forward the review, we should also be doing things such as testing and learning, rather than simply arriving at an answer and trying to implement. A lot of what is going on within the system is testing and learning, so there is a clear objective to do that. There is a balance between national indicators or national targets and the balance between national and local in terms of the improvement mindset. There are elements that you might expect to cascade up, but there are other elements that you would expect to be part of local systems improvement and their use of data using list and source. The third thing is to come back to the cabinet secretary's point about being really clear about framing an overall aim to the system, setting the outcomes and working through the indicators. Having a progression—that is the way in which we took forward the work on the dementia outcomes, which ended up with us having outcomes for which initially we did not have indicators. We had to build the indicators to support what we were trying to achieve rather than the other way around, which is often the case. Harry Burns uses the word flourishing in his report because we want to create a healthy flourishing population. It is nice to hear that you have mentioned in Frees and Galloway a lot this morning, because I am aware of some of the programmes that are being implemented to look at health and social care integration and best way forward for keeping folks out of hospital. I wonder what resources or incentives are available for local authorities to help them to engage in PDSA cycles or change cycles or whatever methodology they choose to use so that we can encourage the flourishing population that we are seeking. Do you know anything about the improvement work and support to— Yes. The work that we are doing at the moment in Frees and Galloway in respect of the dementia activity is being supported by the team at his who support dementia more generally, so they are embedding that in part of the broader change work. I have at Healthcare Improvement Scotland is also providing support across the country to integration authorities around things such as falls, work on admissions, work on delay. They are also supporting some of the work on sleepovers at the moment, but it is in the context that local systems are looking to make a change and own that change locally but require at times some support to be able to give effect, whether that is technical or data or analytical. It is a balance between the national and local. Our objective is primarily that local systems own and want the changes which are the positive changes and find the local solutions that can take that forward. Do you think that Frees and Galloway is a good example of that? Some boards are a bit further ahead with change programmes than others, so obviously boards will learn from each other what works in one area and how it can be adapted for another. We do that through all the improvement programmes. We try to get best practice and share it. Obviously, what might work in the centre of Glasgow might be a bit different from a rural area, given the different resources that can be called upon in those circumstances. If something works well, we would want to share that and help services to develop that in their own area. I want to discuss the area around NHS staff empowerment. One of the areas that I was quite keen on, Harry Burns, was about professional responsibility. In terms of targets, we often set NHS and social care staff. I was interested to find out from the panel your view of how we could change that, because I am sure that I am not the only MSP that meets nurses who are telling us that they are often asked to record information that they do not think is useful. It is giving them empowerment to do their job. I was wondering what the panel's view was on how that needs to change. I will bring Catherine in in a second. My instinct is that we need to listen to front-line staff more around what they think we sometimes get them spending time doing in terms of recording things and all of which takes time. We need to make sure that when we are asking people to record things, we are pretty clear about what the importance of that is and why staffers are fully brought into that and feel that what they are doing is a reason and a purpose to it. Ensuring the engagement of our front-line staff in all of that is very important. I also hear from doctors about why they are looking at that indicator. That means nothing to me clinically. That is not going to be the sort of thing that is going to improve patient outcomes. Why are we measuring it at all? Our involvement of the clinical staff with the expertise is perhaps not traditionally felt that that is something that people want to do. They want to see patients. They want to be at work. I think that we need to make those roles much more attractive. You will have potentially more impact in clinically advising about worthwhile indicators and targets than doing an extra clinic. We do not necessarily value that work that is looking at a national level. I would also say that what we must be careful is about proportion and the burden of data collection for actual results. When I was part of a big maternity audit, I calculated how much time each keystroke took and worked out that we could have employed 50 more midwives a year in the time that it was taking the whole country to record. I am not sure that we look at that very well, either. We keep saying that we should collect more data, collect more data, and that needs to be proportionate to the actual improvement that it will create. If we think about our experience of the work on dementia diagnosis rates, that began back in 2008. Part of the challenge around that was that there was a degree of opposition from general practitioners and others to the idea that we should be doing it at all. The process that we built around that was to be quite clear about the benefits, but also to be quite clear that patient and carer voices were heard as part of the story in terms of what mattered to them and how diagnosis was part of a process of enabling them to move forward with their life and was not seen in the way that some doctors presented it. Often, it is about putting what we are trying to do in context. There are two other components to it, which are also interesting. One is that, generally, where people get feedback and feel a benefit from the information that they provide, they are more likely to provide information. Our system is about ensuring that people see the value and the contextual use of the data. The link to that is the work on the digital strategy, where the objective is to automate more of the collection of data so that it does not require either manual entry or additional work that could be done by machines. The most important thing in that is ensuring that the value can be ascribed back to the value that it has to patients and carers. The more of that data is real-time data, the better, rather than looking back at what happened a year ago. In terms of the existing targets that we have, the only one that the review was suggesting that could potentially be removed is the 18-week referral to treatment target. The suggestion behind that was that there were possible unintended consequences around interfering with clinical decision making and maybe even patient decision making. Do you think that there is still merit in keeping that target, or are there better indicators that we could potentially use to get as the information that we need without the unintended consequences? What I would want to do is to take that and to interrogate it and look at it in more detail. I think that Harry makes a good point, but we do not want to throw the baby out of the bathwater. I think that there is the next phase of work. We would want to take that and look at whether there is a better way of measuring essentially. I think that Harry's point is that we already measure that part of the patient journey, so is it just a re-measurement in a different way of the same patient journey? We want to take that recommendation and look at it in the next phase of work and see what transpires from a closer look at his recommendation. In general, the review took a long time and it was delayed. It seemed a wee bit underwhelming when it came out. Were you expecting more from that, or was that what you expected? We tasked Harry with a big job to do. His review was in two parts. One was more focused on the targets and indicators than the other. It was more on the whole area of health inequality and how we make huge changes. He undertook an enormous task. Maybe the task was too enormous in terms of the remit, but you know what Harry's like. Once he gets going, he wants to have the freedom to look at all of those areas. I think what has transpired from it is a signal in a particular direction that then is for us to take and build on the detail of which. I want to thank him for his work. I think he is a great asset to us. He's able to put his enormous experience to work in a way that might not dot every i and cross every t, but it does give us a direction of travel. It's now our job to take that and to apply the detail going forward. One of the things that the current system allows you and us to do is look across the UK comparators. At the moment, we can see that Scotland's A&E figures were 94.4 for the four hour in England was 84.9. In cancer referrals, Scotland was 86, England was 82. If we look at some of the other indicators, for example, referral to treatment time, which is one of the key ones that Harry wants to get rid of, we were 7.7 per cent lower than in England. If we look at diagnostic tests within six weeks, we are 17 per cent lower. For things like colonoscopy, Scotland was within six weeks. Scotland was sitting at 58 per cent, and England was 93 per cent. We can see significant differences between ourselves, England, Wales and Northern Ireland with the current system. If we change and they don't, how do we then have comparators to hold you to account and for you to make political points about what's happening elsewhere? I think that you made an important point. There are the most comparable health systems, although what I would caveat that with is that quite often when you look behind the data, there are quite variations in the way data is collected, so we're not always measuring apples against apples. It's sometimes apples and pears, but it doesn't always seem like that. I think you made an important point. That's why we have to proceed carefully, because it is helpful for us to benchmark, not just across these islands but actually benchmark elsewhere, but you have to be measuring things more or less in the same way to do that in a way that is meaningful and quite often that's not the case. Taken this forward, I'm going to be very cognisant of that because we don't want to lose our comparators, even where they are challenges to us where we need to make more progress. Be assured we're not going to throw the proverb, we'll maybe out of the bathwater here, we want to maintain an ability to compare and measure in the right way, but we also need a more sophisticated system that has more of a focus on what was the patient outcome and all of that, because often what we measure doesn't give us that bit of the picture and that actually is really important and that's the bit that we want to focus on. Can I ask a couple things maybe just so you can help in winding up Jeff as in relation to the timescale for things moving on and what happens next? So what happens next is the process to take this work forward. Jeff can give you the detail on that and a bit on the time frame as well. Jeff, do you want to see what the thinking is? Yeah, and just to pick up the previous point first, I think the issue with that is whether or not 18-week RTT was a target or not, the data would still be there. So the question is, if you think that Harry draws the distinction within the report between information that is available for accountability of the system and information that is there for improvement, you would still be able to make the comparison whether or not it was a target. In a number of the areas where we're making cross-UK comparisons, the information in the other systems, particularly in Wales, isn't a target. It's just information and so you wouldn't lose that ability. On the process going forward, there are three or four elements to it. First of all, we are doing some of the local testing work in terms of the use of outcomes such as the work in Dumfries and Galloway to actually understand how this would actually work within the system using indicators and outcomes for improvement rather than simple targets applied to NHS boards. Our take on this is that that process of implementation is likely to be more challenging than the process of reaching agreement on what the indicator should be, and we need to have those two things aligned in terms of how we take the change forward. We are working to develop a next-stage process because, as you reflected in respect of Harry's review, what we saw was people's very strong views as to whether things were good or bad and what the answer should be. What we think we need is a more sophisticated process to enable us to make decisions as we crunch through the high-level aim to the outcome to the indicator, learning from organisations and bodies that have done that previously. We will build a process, but we will do that in parallel with the testing work. We also want to build on the learning that we've taken from the integration authorities in terms of their experience of working in that different way during the first 12 months. The other key component that comes back to the digital strategy is the degree to which the information systems that we'll be building under the digital strategy make the collection of appropriate data, both for improvement and accountability, routine rather than an add-on that's applied to the system. That's the process. It's been a long session this morning. We thank you very much for coming along. Just before we move on to private session, it is likely to be my last time convening the committee, so I would like to put on the record my thanks to all of the staff who have helped me over the last two years and all the committee members for their work. I just want to put that on the record before we now move on to private session.