 Welcome to the 28th meeting in 2014 of the Health and Sport Committee. I would ask everyone, as I normally do at this point, to switch off mobile phones as they can sometimes interfere with the sound system. Of course, in saying that, you will notice that some officials and indeed members are using tablets instead of hard copies of papers. Our first item on the agenda today is a decision on whether to take items 3 and 4 in private. Item 3 is consideration of the evidence that we have received on the DAF budget to inform the committee's report. Item 4 is the committee's revised approach to the Assisted Suicide Scotland Bill. Can I have the committee's agreement to take those items in private? That is agreed. We now move to item 2 and begin our second session of annual scrutiny of the Scottish Government staff budget for the coming year 2015-2016. Can I welcome this morning? It seems quite a wee while, cabinet secretary, but I want to welcome to the Cabinet Secretary for Health and Wellbeing, who joins us this morning, along with Christine McLaughlin, Deputy Director of Finance, Health and Wellbeing from the Scottish Government. Welcome to you both. I give the Cabinet Secretary an opportunity to make an opening statement before we move to questions. Thank you very much indeed, convener, and thank you for inviting me to discuss the DAF budget for 2015-16. I welcome the opportunity as always to give evidence this morning on this most important of subjects, ensuring that there is a fair and appropriate funding for the National Health Service in Scotland, an asset that I think is precious to us all. Over the next few years, the demand for health and social care and the circumstances in which it is delivered will be radically different. NHS Scotland must work with its partners across the public and voluntary sectors to ensure that it continues to provide the high-quality health and care services that the people of Scotland expect and deserve, securing the best possible outcomes for people through the care and support that they receive. It is within this context that we have developed our vision that, by 2020, everyone is able to live longer, healthier lives at home or in a homeless setting. During 2012-13, a route map to the 2020 vision for health and social care was developed and has continued to provide a focus on the priorities that will have the greatest impact on achievement of our vision. The route map describes 12 priority areas for action in three domains. One, improving the quality of the care that we provide. Two, improving the health of the population. Three, securing the value and financial sustainability of the health and care services that we provide. I believe that those three domains must be central and indeed are central to our funding commitments that are contained in the 2015-16 draft budget. I will briefly set out how that is the case. We are focused on ensuring that the care that people receive is person-centred, safe and effective. What people expect are services that work in a co-ordinated way with them to understand what matters most in their lives and to build support around achieving the outcomes that are important to patients. Integrating care puts in place a framework to make sure that health and social care services are planned, resourced and delivered together by NHS boards and local authorities to improve outcomes for people using services, their carers and families. That is why we are allocating £100 million to support integrated partnerships and a further £73.5 million, an increase of £53.5 million on the £20 million previously announced to support the development of new models of care in local areas. In addition, ensuring appropriate care and treatment for those people requiring very specialist and often expensive medicines for rare conditions remains a priority. That is why we are investing £40 million through the new medicines fund, which doubles the commitment that I made last year. This investment last year supported the cost of 45 different medicines, benefiting more than 200 patients. By doubling the investment, we will see the fund having an even greater impact in 2015-16. NHS Scotland is a vital role in improving and maintaining the good health of the people of Scotland as a whole and in reducing health inequalities. The 2015-16 draft budget includes additional funding of £4.4 million to support the continued expansion of the family nurse partnership, with a focus on supporting parents and deprived communities. There will be additional funding of £4.6 million to support the extension of the immunisations programme, and £8 million of funding will be used for getting it right for every child programme, supporting the provision of person centres, safe and effective care for women and babies. While Scotland's health is improving, it is improving more slowly than comparable European countries. We will therefore continue to pursue a preventive agenda with the on-going resource committee to alcohol intervention, reducing smoking rates and improving oral health. Securing the value and financial sustainability of the health and care services is also essential. The most dramatic reduction in public spending ever imposed in Scotland by the UK Government has seen a real-terms decrease to the Scottish Government's resource budget of 6.7 per cent since 2010-11. In the face of those cuts, there has been a real-terms increase to the health resource budget of 3.5 per cent over the same period, and we have delivered in our manifesto commitment to pass on the Barnett resource consequentials to health in full. For the first time in 2015-16, the health budget will rise to over £12 billion, and there will be a real-terms increase to the total health budget from 2014-15 to 2015-16. The 2015-16 territorial boards will receive allocation increases of 2.7 per cent, an increase above forecast inflation, reflecting the importance that we attach to protecting front-line point-of-care services. Those boards that are behind the NRAC parity, such as Grampian in Highland, will receive uplifts above the 2.7 per cent average, reflecting our plan to move all boards to within 1 per cent of NRAC parity by 2016-17, based on the current NRAC shares. Furthermore, over and above the full resource consequentials of £202 million that are being passed on to the national health service, £53.5 million has been added to the integration fund, and a further £32 million has been added to the previously published capital budget to support the continued investment in NHS Scotland infrastructure. The new South Glasgow hospitals project will open in the summer of 2015 on time and on budget, while continued focus on the maintenance of the NHS Scotland estate and equipment will be supplemented by the progression of projects being funded through the NPD and hub models, such as the Royal Hospital for Sick Children in Edinburgh and the NHS and Freeson Galway Acute Services redevelopment. The Scottish Government remains committed to publicly funded healthcare services for the people of Scotland, which contribute directly to growth in the Scottish economy. The contrast between Scotland's approach to the health service base and its founding principles and the competition and privatisation being introduced in England is growing ever more pronounced. Our record of achievement is recognised internationally as innovative and aspirational in both its scope and in the potential for improving health and healthcare. For example, Scotland is now regarded as a world leader in patient safety, yet it is recognised that there are serious challenges ahead and that we need to ensure that our plans are developed to meet the changing needs of the people of Scotland. That is why we will publish an update to our 2020 vision in the new year and why in 2015, 2016 and beyond we will, one, increase the role of primary care through a focus on keeping people healthy in the community for as long as possible. Two, integrate health and social care as part of the Scottish Government's commitment to public service reform. Three, further improve the quality of care that we provide through the healthcare quality strategy. Four, focus on reducing health inequalities particularly in the context of benefit cuts that will have the greatest impact on those at risk of ill health. For 2015-16, spending will be prioritised on further improving the quality of care that we provide, improving the health of the population and securing the value and financial sustainability of the health and care services that we provide. That is the approach that we have taken in the health and wellbeing portfolio, as detailed in the 2015-16 draft budget that I commend to the committee. I am happy to answer any questions that the committee has for me this morning, convener. Thank you, cabinet secretary. We move to our first question, which is from Aileen McLeod. I welcome the overall increase of £256 million in the health resource spending, which, as you said, is opening remarks. It will see health spending rise above £12 million for the first time, and it underlines the Government's commitment to protect the NHS resource budget in real terms. With the overall fiscal budget having reduced by 10 per cent since 2010-11 by Westminster, which also includes the big cuts to capital, what is the total health investment in 2014-15 through resource capital and the equivalent capital value of the NPD model and hub programme? What is planned for 2015-16? Is there an increase in the overall health investment, as well as an increase in the real terms for resource and capital combined? I am happy to provide the committee with a detailed analysis of that, because there has obviously been some debate about the comparative figures. You have the figures in cash and in terms of real increases. You have the difference between the resource budget and the capital budget, and you have the value of the NPD and hub capital investment programme, which sometimes is ignored by external analysts. Next year, we reckon that the equivalent value of the NPD and hub programme is of the order of £380 million. Had that been straightforward, capital investment funded in the normal way, the NPD hub programmes would have been equivalent to about £380 million of capital expenditure on top of our normal capital budget next year. If you look at the percentage increases and I will take the cash and the real increases, if you include NPD and hub, the overall health budget will increase in cash terms next year by 3.8 per cent, in real terms by 2.2 per cent. If you exclude the NPD and hub programmes, there is still a cash increase of 1.7 per cent and a real increase of 0.1 per cent. If you cut it real or cash, capital and revenue, then there is a real increase as well as a cash increase next year. I thank you very much, cabinet secretary. That sort of helps to clarify. Just as a follow-up, convener, there was something that you said in your opening remarks, cabinet secretary, about refreshing the 2020 vision. Obviously, one of the core parts to the budget this year has been with the integration fund. How do you plan to refresh the 2020 vision, which is obviously central to making sure that our elderly and vulnerable citizens can live at home or in a homely setting for as long as possible? That is essential to our aims for the Public Bodies Joint Working Scotland Act 2020. I want to refresh it and to develop it. Let me give you an example of where I think it needs refresh. It is becoming very, very clear in both primary and acute care that the particular challenges of the complexity of the care required by the very elderly population require some additional resource and strategy. That is not something that is going to be a one-off. If you look at the long-term aging of the population very clearly, the percentage of the population that is going to be over 65 or over 75 or over 85 is going to rise significantly. It is estimated by the Registrar General that there will be an 82 per cent increase in the over 75-year-olds over the next 25 to 30 years or so. In fact, I was reading the other day that the first person to live till they are 150 in the UK is already born. You never know that it could be somebody on this committee or maybe even sitting at this side of the room. It is now two years since the original 2020 vision was developed, so we want to refresh it and take account of emerging developments that were not as clear two or three years ago. The particular importance of the very elderly is a good example of that and the complexity of care that they require. Secondly, I want to develop it. In particular, I think that it is important for us to look at the capacity requirements to deliver what we are trying to deliver by 2020. As you know, we have substantially increased staffing in the national health service in recent years over the past seven years. If you look at the nursing figures over the past year or two, for example, they have risen significantly. Still, we have significant skill shortages in key areas. For example, in remote rural and island communities, we have major challenges for all kinds of health staff. We have particular challenges in some specialities such as pediatrics and some sub-specialities in cancer. We have a very positive plan in place to identify how many people we need. I have made it clear to the BMA and the Academy of Royal Colleges that we need to increase significantly—this is a point of view that is shared by my colleague Michael Russell, the Cabinet Secretary for Education. We need to significantly increase the number of people going into medical school for the longer term. Because of so many people going part-time, the feminisation of the workforce and all the other trends, we will have to increase significantly the number of people being admitted to medical school to meet future manpower needs and woman power needs in the national health service in 10, 15 or 20 years' time. I am keen that we look at the forecast level and make-up of demand as much as we can. We include, in the 2020 plan, an overall strategic approach to capacity. We have already introduced quite a number of new tools, such as the workforce tool for planning workforce requirements. The bed planning tool is being introduced as well. However, I want to look at the overall picture nationally to see what staffing requirement is needed to deliver. The other big challenge in all of this is the transition from where we are today to where we need to be. We have already, as a society, done that with mental health. We have de-institutionalised a large chunk of mental health services over the last 15 or 20 years. We now need to do something similar with the rest of health provision. We are always going to need hospitals. People will always require, I am sure, specialist acute care, but we do know that there is an awful lot of people in hospital who do not need to be in hospital. We need that transition to get the facilities into the community, into primary care, and social care has a big role to play in that, so that we can stop admitting people to hospital unnecessarily and treat them in the community. In terms of the refresh of the 2020 vision, as well as involving politicians for cross-party support and stakeholders, is there an opportunity for the general public to be involved in a discussion around the future priorities for the NHS? I am keen to involve all those stakeholders. I am also keen to involve all the political parties and the committee. I am looking at how I can do that once we have the basics set out. We should try to take as much of party politics out of as much of the health sector as we possibly can. I know that it is difficult and that I am fully aware of the challenges that that presents for everybody, but I think that it would be helpful if we could have a sensible debate without trying to score points off each other. We are all guilty of it, even I am guilty of it from time to time. I think that it would be helpful if we could have a sensible debate about the way forward. There are major challenges facing the national health service, not least because of the on-going financial constraints that face us. The more we can have a grown-up discussion about it and look at the challenges and how we are going to meet those challenges, the better. Thank you very much, cabinet secretary. Thank you very much for that, cabinet secretary. You know that the committee is up for that honest debate and frank debate, and the more of the politics that we can cut out, the better. Maybe in terms of your introductory remarks with the new regime and less politics, we would have toned some of that down a wee bit. However, can you tell me, cabinet secretary, are you describing new evidence here about the ageing process that has just come to light that can be shared by the committee? I think that the new element of my highlighting convener is the feedback, and we have got no quantitative information at the moment. When you talk to doctors, for example, in accident and emergency departments across Scotland, or talk to GPs, they are beginning to highlight what they see as a group emerging as the very elderly with very complex conditions. They usually describe them as people over the age of 85 with very complex conditions. When they come in to A and E, they require a great deal of complex treatment. We have been dealing with that issue for quite some time, along with yourselves and others. What I was trying to impress you on is our new information here, because what you are saying has been very evident for some considerable time. I am making a distinction between—we have all been very—and there are loads of quantitative evidence on the number of older people and so on, but what I am saying is that the very elderly is emerging as one of the challenges. There is no new evidence. There is no new quantitative evidence other than the age group of people being admitted to A and E. We all accept the problem around here, and we are very anxious to get the facts on the table, and we have come to staff initiatives as well about the new evidence there. One of the themes that has come out over a period of time—we have been through this process where we saw projected staffing levels and a significant increase, for instance, about ally professionals as against a drop in nurses—that policy has changed them. We are now recruiting more nurses, and now you tell us more doctors. What we hear in much of our evidence is how we evaluate what we actually need in the new workforce. Is it more doctors? Is it more nurses? Is it more ally professionals? Is it more carers at a very local level or more skilled carers or upskilling carers at a very local level? How do you evaluate that process? Who has made the decision based on the evidence that will give us a certain outcome that our priority is to recruit more doctors as against any of those other groups? Is it doctors as well as all of those other groups? There are two questions in there. First, how do we better forecast the profile of demand for health and social care in Scotland? I have commissioned, as part of our 2020 planning process, a specific piece of work to be done on not just one-off forecasting but how we establish a more methodological approach to on-going forecasting. When I was in the computer industry, forecasting is where we started. Before we did any budgeting whatsoever, the first thing was to try to get a forecast of the level of demand in the economy for our products and what market share we would get and all the rest of it. I think that we need to do something more systematically than we have done in the past, in health and social care. That is part of the work that is being done in preparation for the reforestation development of the 2020 vision and plan. That is something that we will discuss with people once we will get the results of it. Cabinet Secretary, this morning, you have had discussions with your colleague in education and you have announced that the plan is that we need more doctors coming through the system in the longer term. In the absence of that forecasting and that planning, I think that this is an important question that I have put to myself. It is one of the criticism about how we plan all those services and what our needs are going to be. You have announced doctors and a long-term recruitment process for having a level of order. As you are going to have a systematic approach to overall recruitment, why have we announced a longer-term plan for doctors outwith the detailed work that needs to take place to visualise the shape, size and skills of the new workforce for people who will not be dealt with in the main hospital but in the community? Let me take the example of GPs. We just need to look at the trend in GPs. Although we are by far further ahead in terms of the number of GPs per head, we are by far the top of the table in the UK, but we have had a 5.7 per cent increase in the number of GPs working in the health service in Scotland over the past seven years. The problem, convener, is that ours of the GPs are working and the pattern of work. For example, there is a clear pattern of, first of all, there are many female doctors in GPs than there used to be. To give you an example, an Airshire GP, Lady GP, running her own practice advertised last year for a full-time GP. She had to employ three people part-time in order to get the equivalent full-time GP. The trends are very much there already. The evidence is already there, showing that even to stand still, because of the change in the percentage of doctors now wanting to work part-time or retire early, we know that we are going to need more GPs just to stand still. To meet an ageing population and a growing population—remember Scotland's population is now forecast to grow to just under 6 million over the next 20 to 30 years—we know that we are going to have to need more GPs and overall more doctors. We know that the exact quantity that we require clearly is part of the research that we are doing in looking at longer-term demand, longer-term models of working and all the rest of it. It is not just about the number of patients, it is about the complexity. It is also about the mix of doctors, because we know, for example, that there are far fewer doctors going into being GPs or into A and E departments than was the case maybe 40 or 50 years ago in terms of percentages because of the work-life balance. There is very clear evidence and all that. What I am saying to you is that the evidence is pointing very clearly on the need—I saw Dr Simpson nodding his agreement when I said it—on the need to increase the number of people going into medical schools to fill the pipeline that is required. The exact number has to be a detailed forecasting exercise. There is absolutely nothing new to this. This is just meeting demand. There is not naturally learning that. It has been evident since we have been sitting at this committee in the previous committee. We are recruiting just to stand still and doctors. The point that I am supposed of making is that, with the 2020 vision and the money that is going into the 2020 division, the challenge for us, Government and politicians—and certainly this committee, because we are very much up for this—is how we visualise a new workforce that is not based on the existing model that is just replacing what is there. In the budget process, we are searching for the evidence that what we are doing is changing the nature of how health would be delivered in 2020. That is what we are doing, cabinet secretary. That is what we want to be seriously involved in. That will be informed by the forecasting exercise that we are engaging in at the moment and looking at the modelling of demand as forecast for the future. Forecasting is not an exact science, so you have to build in contingencies and caveats. You then have to translate a national figure into cascading it down to regional and local level. However, we have to get better at forecasting the profile of demand, not just the numbers, but the pattern of demand for patients in Scotland, so that we can cater for that in the future. Just as an additional, you said to Elaine McLeod that you would provide further information for us on figures. I was wondering if you could include in that the figures taking into account health inflation, as well as normal inflation, and maybe draw up for us taking into account the director of finance's paper on how the new money is coming forward to meet the perceived demand on the health service. That would be helpful for us, and it would be nice to provide that in the budget. If the client gives us just a list of the additional information that you are looking for, we will be glad to provide and facilitate that. Rona, that would not be a problem. My question leads on quite well from Duncan's question. It is about the increasing use of private services in the NHS to fill in demand, where that is required and that happens if I am going to be parochial in my area, where the need for locums and the like, where we have difficulty in recruiting into posts, happens. We all know that private services cost an awful lot more to pay for, rather than delivery from the public sector. What are your plans to meet that demand? How do you mean to overcome that in the use of private services in the NHS? First of all, in terms of the overall use of private services, let us get that into perspective. The share of the budget going to the private sector in Scotland last year was 0.84 per cent, which is exactly where it was as a percentage of the budget in the first year when we came in, the percentage that we inherited. As the Auditor General in last week's report pointed out, over the previous year and last year, there was a decline in the use of the private sector in the national health service in Scotland. I have issued directions again this year to the LDP's local delivery planning mechanism guidance to the boards to further reduce the use of the private sector. Where we use the private sector in Scotland is not to replace existing capacity within the national health service, that is what is happening south of the border, that is what is called privatisation or commercialisation. Where we use the private sector in Scotland is where we buy in capacity that we do not have within the health service itself, and that is a big difference. That is not privatising services, that is buying in capacity from elsewhere that we currently do not have. For example, there are some diagnostic tests that are done in the private sector because we do not have the specialism that is required to do them, and from time to time there is provision for treatment in the private sector because we do not have the capacity to do it in the national health service, but that is very different from privatising national health service facilities, national health service procedures and operations and all the rest of it. As I said, the trend— Sorry, I interrupted you. Are you saying that the use of locoms, the use of the provision of nursing association are not included in the figures for private service provision? The locom figures will be included in the staffing, but it is a sub-division of the staffing and locom figures. Let me make a distinction here between nursing staff and medics clinicians. In terms of nursing staff, the percentage of the budget going on agency nursing is now down to 0.1 per cent of the total staffing costs for nurses, but we have typically on average across Scotland about 5 to 6 per cent of all nursing that is provided by bank nurses. The vast majority of nurses are actually nurses who are already working in the national health service, and while I would like to further reduce in some boards the use of bank nursing and more permanent staff, overall having a 5 or 6 per cent level of bank nursing, which is equivalent to supply teachers in the education sector, for example, is a reasonable figure given all the demands in the health service. When it comes to locoms, I am very concerned about the increase in the use of locoms for GPs, for other doctors' positions in A and E and elsewhere, particularly short-term locoms, because if you have a long-term locom, then in terms of patient safety, that is okay. However, if you get a continual churn of short-term locoms, it raises issues of patient safety, as well as the economics of the health service. Typically, a locom doctor costs 180 per cent of the equivalent for an NHS employee or a GP. That is usually made up of 130 per cent of that goes to the doctor because of 100 per cent of the normal pay plus 30 per cent for moving about, and 50 per cent traditionally has gone to an outside agency who arranges the locom, so we are engaged in the process at the moment of bringing in that part of it so that the organisation of the locoms is brought in-house and that chunk of the money that 50 per cent is recycled within the national health service and not going to outside agents. I think that that is very important. That is part of our overall strategy to reduce the use of locoms. The way to do that, of course, is recruiting permanent doctors and to try to address the issues that are causing as difficulty, for example, in attracting people into being a GP. The work-life balance, as I get, is the main reason. In remote rural areas, very often the reason given is not actually the issue around the GP, but it is the issue of finding a job for the spouse. For example, as you know, we have advertised Nardin Amachan for eight GPs. I think that we have only so far had one or two of the most applications. If we talk to the GPs who were there previously, then very often the reason they did not stay long and moved on was because their spouse could not find employment in the area. That is quite a complex issue. There is an overall shortage in certain skills. There is an overall challenge of getting people to go to rural areas and island communities, for example. There is the feminisation of the workforce, which is leading to more part-time work in many cases. There is now evidence—very anecdotal, as we say—that there is a general trend towards part-time working, particularly of people in their late 50s and early 60s leading up to retirement. There is also anecdotal evidence because of the pension changes and the reduction in the cap, that some doctors are reducing their out-of-hours and that some doctors are retiring earlier than they otherwise would have done. Those are all challenges in recruiting and retaining the people that we need. I am aware of those. I have asked the Cabinet Secretary in the past to look at working with other public and private agencies on providing career opportunities for the partners of the staff that they require so that they can relocate and have a job for, say, a year to 18 months until they find something in that area. That is a huge barrier for people moving around fine in the central belt. The moment that you move out of the central belt to people of careers and you are only offering one of them a job, it just does not work. I have done some work with Highlands and Islands Enterprise on that, so maybe the Cabinet Secretary would take an interest in that, and we might be able to push it along that way. As you know, we have funded the Highland Health Board to the tune of £1.5 million on behalf of all rural health boards in Scotland to look at the entire issue of what more we can do to recruit and retain doctors in rural areas. Can I just ask for confirmation in the statement that you made about locums? If I picked you up correctly, you said that locums are not accounted for in the private provision budget but in the staffing budget. That is right. The information on private sector spend is about services for where you use other hospital facilities and things like that. The spend on either nurse agency spend or medical agency spend is not included in that. Is it possible to get a note of that with the other note that the Cabinet Secretary provided? Yes, we can provide the actual cost for this year. As I say, I am very keen that we are in the future. We are in the process of bringing the locums in-house so that the element of the agency, which has always been done by a private agency, is brought in-house because I would rather have the money circulate around the health service than circulating it in the private sector. Has it been the case that it has been accounted for in that way? Yes. No, it has not changed. No, it has not changed. No, it has not changed. No, it has not changed. Yes, that is fine. Gil Paterson. I thank you very much, convener. I listen very carefully to the radio this morning and the convener touched upon it. You made an announcement that you would be spending an additional £40 million on GP services. I wondered if that was new money to the health service. If not, where does it come from for GP practices? Well, overall, as you know, next year, as well as passing on the Barnett consequentials, we have also increased the overall health revenue budget, resource budget, by an additional £61 million. We have specifically funded this initiative by using up the money left in the Commonwealth games reserve that was part of the health portfolio's budget by using the migrant surcharge, which is part of the fallout from some recent Westminster legislation and from redirecting money from elsewhere from lower priority areas of spend into what I think is a top priority is increasing investment in primary care. Overall, I think that this is a worthwhile investment. It is part of a general strategy to further enhance investment in primary care. Other elements in that strategy have included, as part of the guidance to the boards, as part of the LDP process, is for this year and it will be the same for next year, which is an instruction to individual territorial boards to increase their provision for primary care. We have also, as you know, negotiated a three-year contract with the GP committee of the BMA in Scotland and part of that has been substantially reducing the bureaucracy imposed on GPs by that contract so that GPs are freer to spend time with their patients rather than have to fill in forms for the Scottish Government or anywhere else. It is also part of directing funding to our key priorities. For example, we had a £10 million telehealth fund to extend telehealth services eventually to up to another 300,000 people with complex conditions throughout Scotland to match funding from elsewhere. We have the integration fund and that is to help with the transition from where we are to where we need to be in terms of bringing together adult health and social care and treating people at home instead of in hospital. It is all part and parcel of investing heavily in primary care and community facilities as part of the transition from treating so many people in hospital to treating people at home. I noticed that you said that there is a prospect of savings because of that. I wondered how you planned to roll out by board or by how it would impact on individual practices. I am particularly interested—if I talk about moan constituency, we have one part of the constituency, a substantial part that is very deprived, but another part that is quite well off. In the well-off area, you can see the problems in the deprived area. In the well-off area, there happens to be an enormous number of elderly people. The average age is something like 89, I believe, so there is a particular problem there. Will there be a benefit across the board? Yes. One of the influences for doing this was conversations, for example, with a doctor that you are familiar with from Mulgai. One of the points that he made is that more of his very elderly patients are being hospitalised because, quite frankly, they do not have enough facilities and resources in the primary care sector to prevent that from happening. Of course, the worst thing that you can do for somebody of that age is unnecessarily hospitalise them. We have identified three areas to give examples of where that money will be channeled. Practices in which there is an above-average percentage of elderly or very elderly patients will get additional support. Rural communities and remote rural communities at Nyland communities will get additional support because we have particular challenges there. If we take the deep end practices, we have a total of seven link workers working in deep end practices at the moment in Glasgow. Those link workers are clearly making material difference to helping the GP practice with the very challenging situation that they have in their particular areas. The money could help fund additional link workers, for example, if that is what is needed, in more deep end practices. It is very much geared towards where the pressures are in the primary care sector, but we also want, both with the fund and with other funds, to roll out more of the pilots on a permanent basis. For example, we have what is called the St Andrews model, which is very akin to the Nuka model of GP delivery based in Alaska, which has been highly successful in Alaska. You cannot just lift it from Alaska and transplant it, but some underlying principles are very important, which are very successful. We have been piloting the Nuka model in Scotland and, indeed, there is a new Nuka model being opened by Jason Leitch, the director of quality in Edinburgh, on Friday. I would like to roll out more of that, because it is very clear that that particular model for delivering GP services can be very successful in dramatically improving the outcomes achieved by patients and reducing, simultaneously, some of the pressure on GPs. I am keen to look at new ways of working. We have also done some pilots with telehealth services, run by GPs for older people, with very complex conditions. A number of those pilots have resulted during the pilot phase of a reduction of up to 70 per cent in hospitalisation of patients. Again, through the telehealth fund, the integration fund, the primary care fund, we want to try to roll out as much of that as we possibly can, as quickly as we can. Richard Simpson Yes. I think that if I could just start by saying that my general disappointment is that, 15 years on, we still got nine pages or 10 pages of 185 pages in the budget paper devoted all to health, and we are still in the situation that we are grappling for information. Having said that, I welcome the fact that the consensus that was achieved in June on the 2020 vision principles between all five parties is to be continued and look forward to participating in that. What the cabinet secretary has just been talking about in terms of distribution to primary care is very welcome, but it is interesting that what you were saying was that the distribution would be on the basis of those with a very elderly population, remote and rural population, and those in the deep end, which is, of course, inequalities, which is NRAC. Those are the three principles of NRAC, and that was the basis of distribution to health boards since 1999, since they are a butnot formula. It has been around for 18 years, and yet what we have not achieved is the move from the health board funding into those practices. I welcome the fact that the centre is now going to be more directional in this respect. I could ask him if he could provide us with a link to the local development plans, because I find it difficult in getting access to those. The local development plans for last year or for the current year would be very useful to see those because we were supposed to see primary care being highlighted within those, and the ones that I have been able to attain I cannot really see that at all, so I would value that. However, my main question relates to the section of improving health and better public health. The health improvement and health equalities budget, which is budgeted this year for £55.6 million, but in the draft plans that were in the draft budget last year, it was £64.4 million. Even allowing for the transfer to family nurse partnership of £4.4 million, there has actually been a cut since three years ago in the health improvement and health inequalities budget. If we look down that list, immunisations are up, yes, and I know that we have new rotavirus and shingles vaccination programmes. Very welcome, good preventive measures, excellent pandemic flu preparation down, because of course we are just restocking on that. However, if we come to tobacco and alcohol, we will almost use over a period of almost four years. Those have not increased and in the case of the alcohol budget, it has actually gone down. I am really trying to grapple with what all the very positive and nice things that the cabinet secretary has been saying about shifting to prevention, about the whole Christie agenda and the agenda that this committee has repeatedly talked about over the years. I am trying to equate that with a budget in which health improvements cut, tobacco control is cut in real terms, a flat line for three or four years now, and alcohol must be used down. How does that equate? As you probably know, if you take alcohol abuse, we will be making substantial progress on that in recent years, not as much as any of us would like. However, I think that the problem—I will make a general point about the budget and I take the point about presentation—is that some of the figures produced by the Royal College of GPs over the last couple of days are figures that we do not recognise and we think that we know where they are making a mistake. One of the mistakes being made is taking one line that says GMS contract and assuming that that is the totality of what is going into GPs and into primary care and, similarly, with healthcare improvement and prevention activity. I think that there is a danger in taking one particular budget line that has headlined that and assuming that that is the totality, because it is not. As you know, Dr Simpson, there are many other aspects of the health budget, including the budgets of the territorial boards where there is work going on that is not necessarily feeding into that budget line, because we do not put it in twice. I think that you have to look at the total picture. If you look at the total picture on alcohol and on tobacco, the strategies that we are following are the right strategies. Indeed, the latest consultation that we have produced, which covers, for example, e-cigarettes, I would hope that we will get a broad consensus on our approach to that. Most of those measures do not involve any money to be spent by the health portfolio. They are the money that would be spent would be enforcement monies probably through the justice budget or environmental health budget and local government. The important thing that I think is not what is in the particular budget line, the important thing is the overall strategy working. There are clear signs that our smoking strategy is working in many respects, but I think that it would work a lot better if it had minimum unit pricing, obviously. Particularly in alcohol, I think that we are achieving some success with a long way to go, but I think that there are clearly signs that we are having a degree of success. I do not think that you can just take a budget line in the budget and relate that to success or failure in terms of the overall strategy, because there are many other parts of our budget and, indeed, other people's budgets that commit to deciding the success or failure of those strategies. Well, if I can take the tobacco control area, I think that I would agree with you on alcohol. I think that, since 2005, indeed, the Licensing Act, which is a minister and which is responsible for initiating the stuff on that with a commission, and since 2005 the alcohol consumption in Scotland has been dropping, although it is flatlined in the last year, I think, but it has dropped, and the discounting part of the bill has actually caused an increased drop beyond the drop in England, which is parallel, but if we take tobacco, which is the one that really worries me, because it has actually flatlined for the last few years, we are not, you know, we have got it down to about 23 per cent roughly, I think, but if you take Australia, even before plain packaging it was down at 15 per cent, you know, we seem to be stuck, and if you subdivide it into bits, we're stuck on, you know, we've got little progress in terms of the variation between different socioeconomic groups, you know, the more deprived communities are still smoking around 38 per cent, you know, significant numbers, so, you know, and the consequences for the health budget, of course, are absolutely enormous, so I'm afraid I just don't accept in the tobacco control area, and the alcohol, I understand, because you've got alcohol, brief interventions, the whole justice agenda as well, so, you know, we can agree that maybe that's an area where things are happening, but tobacco control really does worry me that we are not making progress on that, and if I can take one particular instance, the improvements and pregnancy smoking rates are really tiny, we're stuck at 18 or 19 per cent on that, really significant, and yet there have been pilots in Dundee of, you know, paying people to come off, I know we're attacked in daily mail and places for that, but if it works, it works, and if it works, we should support it, and, you know, so I just don't see where we're going with that, and I think the budget line reflects, if I may say so, Cabinet Secretary, a complacency which your strategy doesn't reflect, so it's as usual, we've got great strategy, but, you know, I just question the implementation. Can I give you an example? I mean, my view is that we spend a lot on public health, every board has a public health department with a director of public health with very substantial resources. Now, my own feeling is that we're not perhaps maximising the impact of our public health resource, and I have asked the acting chief medical officer, Aileen Keill, to look at the whole area of our public health resource to see where we can make it much more effective, because I don't believe we're doing as much, I think, because it's divided into 14 might be one of the reasons, but we need to look, I don't want to prejudice the outcome of what Aileen, the work Aileen, Dr Keill is doing. It's not just in terms of tobacco and alcohol, I think, in terms of our public health effort and strategy, we also could and should be doing more in terms of exercise and diet, because if you look at the three biggest killers in Scotland and many other diseases, such as stroke, heart and cancer, if we could get an exercise regime in the population, even a modest amount of walking by people and an improvement in their diet, then through time we will see very substantial improvements in reducing the incidence of cancer, heart and heart attacks and stroke, if we are unable to do that. In general terms, I think that we do need to look at how we make far, far greater use of our public health resource in the prevention agenda, concentrating on exercise, diet, tobacco and alcohol and to some extent drugs abuse, although that's more of a wider issue. I say so just in conclusion, convenient for my this questioning. I entirely agree with you that our public health, because it's based in the health boards and the health boards are primarily focused on the acute sector, that they are missing something quite strongly. It's not to have cast dispersions at the individuals involved, many of them are excellent, but nevertheless there's a problem. It is probably the only area in which I think what's happening in England is something that we should look at. I think that the cabinet secretary and I would agree that most of what's happening in England is stuff that we don't want to even go near or touch, but in public health they have moved that to the local authorities and to the community planning partnership equivalents in England, the health and wellbeing boards, etc. We need to look very closely at the possibility of moving public health into the local authority sector where it can have an effect on exactly the things that you're talking about, because many of the things like licensing availability of licences, etc, are all within the purview of the local authority. Frankly, public health input to those from my experience is insufficient on, say, alcohol availability licences to allow the licensing boards to confront the sheriffs and say that we don't want to give a licence in this area. They just don't have the backing of the public health in the way that they need it. I absolutely agree that there's a debate behind my own preference, is that public health as a function, since the second world war, has been a bit of a yo-yo in terms of where it's sat. It originally sat within local authorities, then under the Heath reforms in the early 70s it was transferred to the health sector and it's remained there ever since, but local authorities clearly have a role to play. I actually think that since we're creating 32 integrated partnerships, they could have a much bigger role in that, because they bring together the role of the health service with the local authorities. It seems to me that there's a real opportunity here for us to do much, much more on the public health agenda. Good day, we'll have a session on that on its own, I think. Bob Doris. Thanks, convener. Opportunity moment for a quick supplementary on Dr Simpson was just saying there, cabinet secretary. We've got a community empowerment bill going through the Scottish Parliament. I've met Harry Burns here, timing again. The former chief medical officer, he would talk about tackling alienation, exhalation and lack of empowerment, has been key drivers to get people to make positive lifestyle choices such as smoking cessation, alcohol reduction, increased exercise and the like. So, just in the spirit of Dr Simpson's line of questioning as well, in terms of the public health agenda, will the cabinet secretary be doing any work in conjunction with, I think it's Derek Mackay that's taking forward that piece of work going forward to map out positive public health benefits of community empowerment, particularly in the most deprived communities? Because I think what Dr Simpson is driving at was the connectivity between those who are actually on the ground at the grassroots, trying to deliver or sometimes lecture a public health message rather than capacity build within communities until they make positive lifestyle choices rather than just focus on telling people what they're doing wrong. So, is there any connectivity between your department and what the minister's doing? Yeah, absolutely. There is actually a ministerial group looking at the future of community planning partnerships and they need to make them much more proactive in terms of getting greater complementarity and co-ordination between all the public services at a local level. Obviously, the health boards and the integrated boards as well as the local authorities obviously have a major role to play in that because, as Richard Simpson rightly said, if you take an issue like public health, an issue like alcohol, it's not just a health service issue, it's a local authority issue, it's an education issue and it's a criminal justice issue just to pick three departments that would be involved in that. So, at local level, I think the community planning partnerships are the tools to get an agreed strategy with everybody then delivering their respective bits of the strategy in a joined-up way, in a co-ordinated way, and that is how we are developing the community planning partnerships for the future so that they can be much more effective in doing that than they've quite frankly been in the past. I'm glad that you mentioned community planning partnerships, but I won't go down the tangent of that, other than to put it on the record, convener, of saying that, of course, community should be involved in community planning and not just erstwhile officials telling communities what they need and that's sometimes a structural problem with community planning partnerships, but I think we'll leave that sitting there. It can be a disempowerment. For another committee? Well, I merely leave that sitting, but what is in this committee's budget today, cabinet secretary, is the budget line in relation to health and social care integration. I listened to your opening remarks and I think I heard you talk about the £100 million that sits within the baseline budget of territorial health boards and the £73.5 million is a significant increase in the stand-alone budget line within the overall health budget, so that's a significant increase in expenditure. Is that money that was previously maybe considered to be change fund money, for example? Is it some of it in relation to that? Because obviously there was change fund resources before for innovation with health boards and local authorities in the third sector to do the kind of integration type of work, so how should we view the budget line in the house intended to be used? Let me make it absolutely clear that the integration fund is not a successor fund to the change funds. The integration fund is very specifically about helping to manage an oil of wheels of the transition from where we are, where we don't treat people enough in the community and we over-hospitalise in terms of healthcare in Scotland. It's estimated that a third of the people who are in Scottish hospitals at any one time, if the facilities existed in the community, could be treated and treated more effectively in the community, but it's how you get from where we are to where we need to be and that £100 million as part of that jigsaw is to help the transition. It's very specifically—we can send you the detail, but Michael Matheson, my colleagues, has been leading on this—to develop it so that it helps the transition into much greater treatment at home rather than hospitalisation. It's just part of the overall budget. It wasn't money specifically taken from anywhere. When we were doing the review, we identified that part of the money should be allocated to that function. The £73.5 million that we can view as the national government will work with health boards and local authority partners to determine the best use of that, but the £100 million that is set within the territory of health boards is for them to work collegially with local authorities to derive the changes that are needed. We've had heavy stakeholder involvement across the board, including the third sector, on how to make the best use of that money to achieve the objective, which, as I say, is the transition. There are other initiatives that are within the health service primarily, or in social care or jointly, which are also part and parcel of the overall strategy of making that transition. Hospital at Home, which is a programme initiated by NHS Lanarkshire, across other parts of the health service in Scotland, is another part of the transition from treating people in hospital to treating them at home. The integration fund should be seen within that wider context. That is part of the strategic change that we need to make in the next five years. I was just trying to tease out how the £100 million is for locally set priorities, third sector, health board and local authority, for using the principles that the Cabinet Secretary for Health and Sport said about the £73.5 million, which is much more of a national strategy on how that money is directed. The reason that I mentioned the change fund, of course, is that that was to drive local pilots across 32 local authorities in Scotland. Although they were not successful, that was okay. That is the point of local pilots to see what flies and what does not. However, they were successful for transition to me from temporary funding and innovation to drive change to be embedded in what territorial health boards and local authorities do as core business, in other words, to mainstream the funding of that. I am sure that this committee must be ready soon to do a final review of how successful change funds have been across the country. However, going back to the health and social care integration fund, I suppose what I am hoping to tease out is whether or not we should expect—I hope that the answer will be no—some of that £100 million to continue with some of the pilots that have been done under the change fund to keep them going, that could be a new budget line for them to be used rather than mainstreamed into core service provision. The £100 million, cabinet secretary, is that for new things, rather than to be able to direct service provision for things that health boards and local authorities in the voluntary sector collegially should be doing anyway? I am trying to tease out how the money should be spent. I think that if you start to pick out individual bits of money and then try to over-describe them, I think that the key thing is that we have this overall strategic approach, which is to go from where we are to where we need to be, which is about treating people at home much more than we are doing today. There are a number of things that we need to do to do that. For example, we need to get hospital at home much more. We need to develop telehealth and telemedicine services along the lines that I have described many times to reduce the level of hospitalisation. We need to invest in primary care services more targeted at the areas that I have announced on this morning. The integration fund is also part of that. Jigsaw, both the £100 million, which is very much aimed at the next generation coming into being elderly, are treated differently in terms of how they go through the system and the service provision from days gone by. The £73 million is for—and that is delivered at local level—the £73 million is for national initiatives. The £10 million telehealth money comes out of the £73 million, for example. The £40 million that I announced this morning comes out of the £73 million. I am hoping to increase the £73 million, if I can, in future. However, the integration fund is not about funding left-over projects from the change fund, if I can put it that way. Anything that has been successful during the change fund period, the whole idea was that it would be mainstream. Let me give you an example. One of the projects funded by the change fund was the creation of a step-up, step-down facility in Midlothian. That is for people on-route to hospital or more usually being discharged from hospital. As you know, we have a mounting problem at the moment with delayed discharges. We had made substantial progress, but this year there has been a major increase in the number of delayed discharges, particularly in specific local authority areas. One of the reasons for that is that those local authorities do not have the places or the funding that they say that they are always ready to hand at the right time to fund people to go into a residential care facility, or because the house is not ready with adaptations or whatever to allow them to be discharged from hospital. What Midlothian has done is to create a step-up, step-down facility so that if you are ready to be discharged medically but your house is not ready for you to go back to your house or the support package is not in place, you go into this mid-way situation where you will be properly looked after. Any medical needs that you have that do not require hospitalisation will continue to be met and you can stay there and be well looked after until you are ready to go home when the care package is in place or when you are physically fit enough to go home. I now want to see at least one step-up, step-down facility in every part of Scotland, because, quite frankly, it is a fundamental part of the jigsaw if we are to achieve our objectives of getting people out of hospital and not having them stay in hospital longer than they need to be. I now would expect the integration board in Midlothian to continue to fund that facility on a permanent mainstream basis. That is a very good example of what we expect to happen. The change fund projects, when evaluated that they have not worked particularly well, some of them will probably come to an end. Some of them may reappear in a modified format, but the integration fund is not about funding the continuation of change fund projects. That is helpful, and I am sure that local authorities and health boards are listening to those words when we come back to scrutinise their expenditure, as we have all done in a few months time. I think that it is important to have clarity around that. I had one other budget line that I wanted to look at, convener, and that was in relation to mental health improvement and service delivery. I am picking one where I can see an increase in it to ask what the thinking is behind that. Before this morning, I looked at the Sam H worried sick report in relation to how they believe that the pressures welfare reform has put on some of the most vulnerable people in relation to mental health services and 98 per cent of their clients that they serve believe that their mental health is deteriorated because of welfare reforms and cuts by the UK Government. That might be a complete red herm, cabinet secretary, but I have no idea whether the uplift in that is a recognition to some of the additional pressures that are building on that, whether that could be included within the Scottish Government to talk about £82 million a year that is meant to mitigate welfare reforms across Scotland. Does that sit within the health budget when you come to that figure? I am just trying to tease out because that is a significant uplift that I am seeing, the 6.3 per cent uplift that I welcome. It is just to get some of the rationale behind how that feeds into it. When I did that Sam H report, I was wondering if there was a connectivity there between the decision that the Government had made and those kind of factors. Excuse me, can I say that we do recognise that the financial pressures in people, particularly people on benefit, is undoubtedly leading to additional stress and in some cases to more severe mental health problems. The role of the link worker in deep end practices is actually one of the things that they have been doing is people who do suffer problems because of financial pressure. There are very often a lot of support mechanisms available, but people do not know about them. What the link worker does is put them in touch with those services. This particular line that you referred to, Bob, is that the vast bulk of that is responding to the challenge of dementia. Some of it is for three- and four-year-old parenting. It is part of our strategy in getting right for every child, but dementia obviously presents a major challenge. We have been very successful compared to other parts of the UK in terms of the rate of diagnosis of dementia. It is now 20 per cent higher than anyone else, mainly because of what we do when people are admitted to hospital in terms of the health checks that they undergo in dementia. It is one of them for particularly older people, but this is recognising the additional resource primarily that needs to go into dementia care. That is helpful. Can you hear her, thank you very much? I suppose that that exchange highlights my humble opinion that some of the challenges that we have here about providing scrutiny. The £100 million that the cabinet secretary described was available was money taken from anywhere. It sums up the challenge that we have in terms of providing scrutiny, because £100 million came from somewhere. The other aspect of this is about how when any amount of money, whether it be the total budget—I think that Professor Bell put it last week in a provocative way, not a controversial way, when he asked who is making the decisions about the investment in mental health rather than childcare? Who is making the evaluations or are we just going along with the draft budget? Because we are locked into doing—we are going back to my original theme—doing what we have to do that prevents us from innovating and making those evaluations about where we are going to get the best health benefit. Who made the decision that it was the important decision to make to increase that mental health line to change the nature and get the outcomes that we would want there? Who made that decision? Was that decision based on just the basic demand and need? Was it based on changing the services? Was it based on getting a greater bang for your buck for that £100 million? What drives those decisions within Government to ensure that we get in a very constrained situation the absolute best value for quality outputs? That is the challenge that was recorded and the theme that was recorded. All of the evidence that we have had is who is making those decisions, how accountable are we in this whole process and how transparent is this process so that we can see where we are spending, why we are spending it and here are the outcomes that justify those decisions? In that line, that is driven by the needs of a dementia strategy, which we have agreed and published. We need to fund the implementation of the dementia strategy. Similarly, in relation to children, the child care and childcare strategy and the quality strategy all feed into that. You make a valid point about how we judge where we get best value for money and where our resources should be put in the future to get the best bang for the buck, as George Redd used to call it. We have got a fair amount of work going on throughout Government, including in the health department, looking at that. For example—I will get Christine to give you some more detail—one of our organisations that promotes good practice quest is specifically looking at how we can better evaluate the impact of programmes or the likely impact of programmes to help us to decide where best to channel our resources. There is also work going on in other areas, for example Health Scotland, which does a lot of work on alcohol abuse. One of the things that they have been doing is looking at the impact of particular policies or particular spend. In individual parts, before they decide what the right strategy is, they are looking at the impact of what is worked and what is elsewhere. Minimum unit pricing, for example, if you look at the impact of minimum unit pricing in Canada, a lot of that originated from some of the work that we have seen elsewhere in terms of what works and what does not work. He will take dementia. The Japanese dementia strategy is taking into account what we are doing in Scotland, because one of the innovative things that we are doing in Scotland is heavily involving people with dementia in the design and development of the dementia strategy and the way forward. That has been a huge plus in terms of the quality of the strategy and internationally renowned as very good practice indeed. There is no single influence. There is a range of influences, but in an ideal world we would be able to sit and look at if we spend money there, that will be the impact that we will get. If we spend it there, that is the impact that we will get. Of course, a lot of that is changing goalposts as things change, but you are absolutely right. We need, not just in Scotland but across the developed world, to get better at evaluating the impact of programmes and where you get the best bang for the buck. I am more interested in how that influences spending. I think that it was a major focus in terms of Government strategies, targets and objectives and how the budget either follows or drives that. If you have had a briefing about the sessions that we had last week, Christine McLaughlin nodding, and she is off to that. I think that the committee would be interested in understanding better how the decision process is influenced by, well, just how it is influenced in this thing. Last week, there was no problem in gathering statistics about any given thing in the health service, but I think that it was generally recognised that there is a plethora of these facts and figures that do not, as a consequence, inform the decision making process and, indeed, the cloud in obstructing, in some ways, the transparency. We are interested, if we are going to have an honest debate, to be looking at the factual situation, the challenges and share those challenges. I do not know whether you want to bring in Christine McLaughlin. Can I just say, if you take something like health, year to year, a fair chunk of the budget is already bespoke, because we have 24 A and E departments, we have 38 acute hospitals, we have a portfolio of community hospitals, mental health hospitals, GP practices and all the rest of it. What you tend to look at are two things. I think that the additional money that you are getting is year to year. For next year, we are getting £61 million on top of the Barnett consequentials. So where can we most effectively spend that money to achieve the Government's health objectives and to fit in with our strategy? We tried to do that. The second thing is that, within the bespoke funding, there are possible changes that we can make. Let me give you an example. Initially, that started in Ayrshire and Am. It is now being rolled out across the health service in Scotland. It has completely redesigned its orthopaedic provision, and it provides what is described as an MSK service. As a result of that redesign, the need for operations went down by 25 per cent. That immediately frees up resource in theatres and all over the place that can then be used for other things. Very clearly, at health board level in particular, when that happens, they then make a decision. The resources that are freeing up, they then use to do something else that is appropriate. You have got these two broad things. Where do you get new money every year? There is a very conscious decision made about the best way to spend that money based on what we are trying to achieve and where we know we can have good impact. In terms of the day-to-day work that is going on, there is continual improvement and redesign of services. When that frees up resource, the health board will reuse that resource elsewhere. It is like the efficiency savings. Unlike south of the border, the efficiency savings are recycled within each board to improve service provision. That is another example of where we change the use of resource on a regular basis. I will get Christine to give you some more detail on that. I will hopefully get a chance to speak about the other pressures on boards and the political decisions that we are all party to impact on them. There is the spending review approach, which is looking at over the three-year period. As part of that, everything that ends up in that spending review will have been assessed. There is a straightforward template, which is a bit more detailed than the impact assessment template, where we are looking at everything from whether it is a legislative requirement, whether it is about supporting build development, whether it is a key priority area for the Government in taking through and the programmes that are already in place and looking at whether it is right for them to continue. There is an assessment against things such as the support of the quality strategy and an assessment against the impact on outcomes that are agreed. That exercise takes place for the spending review, and it is refreshed each year as we do the draft budget exercise. There is an element of challenge and scrutiny on all the lines that are in the documentation that you have today, as well as the assessment about the level of uplift for boards, what is expected from boards to deliver within that and decisions on things such as the amount of money to go into additional enrack funding. Each of those decisions are taken not driven by the financial position, but how do we deliver the priorities for Government as well as doing it in a way that is within the financial envelope and looking at the public value that is delivered from within it? We are looking to strengthen that approach as well and look at a more fundamental priority-based review of particularly the spend within the directorates on the policy areas and what you see here in the level 3 and 4 detail. We will be kicking that off shortly in preparation for what is in 2015-16, but we are also looking at that at 2016-17. There is a process in place that we could still do more in terms of quantification of outcomes, and there is work that Quest are doing to look to have a more consistent way in which we identify the outcomes that are being delivered by individual projects. A good example of that probably is in the child smile programme and oral improvements generally. There is good evidence on the outcomes that are delivered and that is the kind of approach that we need to have across more of our programme lines so that we can have an assessment of the public value. So, the transformational opportunities are limited to new money that has come into the system rather than the bulk of the finances that are already being spoken for? I think that what we are saying is that we always need to be looking and we do. There is never an assumption that a spend will continue. What we look for is that there is a fit with the quality strategy or that there is a legislative requirement that means that that spend has to continue. However, there is no assumption when we enter the budget process that any line item will continue. What Mr Neil is referring to is that, in terms of the large proportion of the budget that goes to board baselines, the decision there is mainly about what performance targets we expect from boards with that funding and what level of our total budget goes on an uplift to those boards. The model that you have described for prioritising and allocation is that model that has been consistent over the period of time. The evidence that we have, I accept and I am sure other members accept that what we are dealing with here is a decade old problem. This is not the cabinet secretary's responsibility. Who happens to be sitting there this month or somebody else next month or whatever? The dogs are barking, but you have a decade old problem here when there was, indeed, as been testified to a lot more money going into the system, indeed, that it was difficult to spend. Now we are in a situation where every pound is counted on. How has it adjusted over that decade period? Has it adjusted or has it just been that type of model that has looked to deal with the immediate priorities and demands rather than using it for the transformation? One of the very noticeable differences in the past couple of years has been the assumption that the status quo does not continue, that every line needs to be justified and that it is not an assumption that it will just either flat line or increase, but that in some lines, as you will see in the budget, there is no evidence to support it or there is very clear feedback from those in receipt of that funding, that that is not the best use of funds. In those situations, we will look to decrease or to take that funding away within a year. I am no expert on this at all, but it does seem pretty parochial. You are looking at a line. How do we use the budget to transform the service that we currently provide? How do we continue to be world class? It is not about looking at a line by line, is it not? Start with the big picture. Obviously, the big picture decision that we took early on when the crash happened—well, a couple of things. First of all, one of the decisions that we took was pay restraint versus a policy of no compulsory redundancies. That was a strategic decision, and once you have taken that strategic decision, then certain financial consequences follow. Another strategic decision that we took was that, in terms of the Scottish Consolidated Fund, we would pass on the Barnett consequentials for health. Obviously, that has a knock-on effect on all the other budgets. By definition, if you are passing on the Barnett consequentials for health, there is not as much of the Barnett consequentials for the other services. You start at that strategic level, but then, when you get down to board level, they have to decide within each board what their particular priorities are. I do not understand that, but we are grappling with the evidence that we have. When that decision was taken to ringfence, we do not disagree with that, that meant that there was less money for local government to deliver the transformation, to deliver more care in the community. When the decision was made for no compulsory redundancy, that has an impact on patients and the system. Who made those decisions? The full knowledge about the other impacts. A couple of questions, if I may, to get back to the convener that I mentioned the eight HPs. As the health service changes, the shape of changes, there is more focus on community delivery of services. I am sure that the eight HPs are right that there will be more demand for their services, because if something changes, the 10th foot demand is there. Their contention is that a lot of those workforce developments elsewhere are funded, but, as yet, there is not funding for the increased expectations of the eight HPs. They have a significant concern about that. Would you like to comment on that? We are talking to the eight HPs about that particular subject. I think that there is a difference between, say, a workforce development plan for nursing and a workforce development plan for allied health professionals, because nursing is one profession. The allied health professions currently include 12 different professions. Obviously, there are 12 different challenges, but we are in active discussion. We recognise that, number one, the role of allied health professionals is going to expand. Secondly, we need workforce development plans for every one of the allied health professionals. The more health visitors you have, the more people are going to be referred to eight HPs. I referred earlier to how we need to, in future, deliver GP and primary care services. That is another example where allied health professionals will have a greater role, in particular. For example, if you look at Alaska, the impact when they redesigned the primary care GP services in Alaska was on the use of clinical psychologists. That was a single biggest expansion. I absolutely accept the point that you are making. I look forward to developments on that, because it was a significant concern that we raised. The other thing that is quite separate is the new medicines fund. Clearly, the £40 million for this year is very welcome for that. Is that a one-off? If it is not, how do you plan to manage it or demand for it in future years? As more new medicines come on stream, and what kind of rates of growth would you consider acceptable? We have announced that for up to the period of 2016. The reason for that is twofold. Number one is based on our best estimate. It is funded, as you know, by the PPRS revenue. That is our best estimate of the PPRS revenue. That is a completely new source of revenue. It is still a bit of thumb in the air as to what it will be in three, four or five years time. I did not think that it was wise to announce something that I was not sure how much funding it would have beyond the next two years. The second reason is that we ourselves do not know our overall budget beyond 2016-17. Obviously, the new Government that is elected at Westminster next year will presumably undertake a new three-year spending review. It will be probably at least this time next year before we know what funding is available to us beyond 2016-17. I thought that it was prudent to get this money set aside using the PPRS revenue for the new medicines fund, but to announce the actual sum for the two-year period, I would see the need for a new medicines fund in principle as a more permanent feature of what we need to provide. That is helpful, because it sets it in context. I was not sure where it was going, and obviously you are not either. I think that we will need to continue to need it. One of the subjects that you have not been asked about, which was touched on earlier on by Christine McLaughlin, was the factor of targets. You did not say that you are looking for party consensus in regards to targets. Many Governments make a target in the other party who is not in government attacks the target because you have not either met it or you are failing to raise the target. To my mind, the health board spending in the health service can also be a target driven in the factor that if a health board does not meet its target on a particular issue, it will then reallocate that money in order to meet the target. Can you tell me how many targets presently we have in place? What is your opinion in regards to whether we have too many targets in place or should we have more, or should we be in the consensus that you are looking for between political parties discuss what targets should be in place? At the moment, if you look at the heat targets, which are the main targets that we measure in the health service, not the only ones but the main ones, there are 12-heat targets. Most of those actually have to be achieved by March 2015, i.e. the end of the current financial year. We need to look at where we go from there in terms of targets. I think that there are some of the targets that have driven real improvement in the health service in recent years. The treatment time guarantee has driven down waiting lists from six months, nine months, sometimes a year, a decade ago, to 12 weeks for most procedures now. There are two boards that are not there yet but we are heading in that direction. Similarly, the turnaround time in accident and emergency of four hours, every clinician that I speak to says that do not change that target because it is driven by clinical need and it is a very good indication for them not just of performance but of the standard of care that is being provided. I do think that some of the other targets—there is room for a debate on targets and how do we measure success in the national health service. When I said earlier about today politicised, for example, we have a major challenge, as I said earlier, with delayed discharges because local authorities rightly or wrongly are finding it difficult to provide social care assessments or to place people in a timuous way. That is particularly over the past six months or so has become a real problem. That has a knock-on impact on our ability to meet the A&E target. Why does it have a knock-on impact? The beds that need to be freed up to accommodate people coming out of A&E are still filled up with people who are medically fit to be discharged but are not discharged and still in a hospital bed because the local authority is not able to do the social care assessment or find them a residential place. You have to look at the whole-system approach. There is no doubt at all that patient flow is key to the whole thing because if you do not have the proper flow of patients, another example of the importance of patient flow is that if your discharging is 10 per cent or less of the total to be discharged each day, if 10 per cent or less are being discharged by lunchtime, the chances are that you will find it difficult to accommodate the people coming from A&E. If that figure instead of being 10 per cent is 40 per cent and I was in Crosshouse last week and they have got it up to 40 per cent for most of their wars, including other pedigs, and the difference that they have noticed in terms of the flow of patients from A&E into the wars is fantastic. Very often, the reason why such a small percentage of patients are discharged before lunch is that there is nothing to do with their medical condition, it is to do with the timing of the consultants round, it is to do with the availability of pharmacy for the patient going home, it is the availability of transport for the patient going home, it is about co-ordination and management rather than medicine per se. I think that there is a huge room for us to make real advances in those areas. In part, that is driven by the A&E target, which, as I say, clinicians tell me, every clinician I have ever asked a question to tells me, do not abandon the four-hour target for the A&E turnaround, because it is driving clinical excellence as well as performance per se. There are some targets, including ones that have to be met by the end of March next year, we have to decide whether we keep those going, whether we redefine them, whether we abandon them, the ones that we have achieved, whether they become part of the lexicon and become officially standards rather than targets. As I say, there is a debate to be had. I am happy to have an open discussion about how we measure success in the national health and social care system. We also have to now take account of the nine strategic outcomes that have been agreed in terms of the integrated boards and what they have to achieve. Clearly, they need to be reconciled with and complementary to any targets that we set in the future. There are a number of events that demand us to look at targets, but my personal view is that the key ones on cancer waiting times, on TTG and on A&E, for example, is that we should keep those, because they are, I think, a good measure of the quality of provision and not just the quantity of provision. Can I welcome your comments? Most of the comments that you have made this morning, and all the points that you are making—actually, I was in Wishaw hospital yesterday when I was visiting a friend of the family, and basically the point that this lady is of the elderly situation. She went back into hospital for a second time because of the condition, but she is waiting to get back out. I welcome the comments that you make about the look at some stage where people can come out of hospital and go into a case situation before they go to the house. I know that you are trying to be very innovative in many of the things that you have done in the past, and a couple of years that you have been the Cabinet Secretary. The one-touch subject that most people have come on to is the PPP-PFI. I know that you have answered many questions in the chamber on that. Is there any way out of this? Is there any new information that we can look at on how to recoup or reduce the cost that is continually, which could free up millions of pounds? Is there any further in relation to that situation? We have a team working under the Scottish Futures Trust to look at aspects of PFI contracts. I was not satisfied that the individual boards were always monitoring those contracts because they are very hefty documents to say the least. It is a way of getting as much value for money as we could. We cannot renaig, we cannot afford to buy them out because there would be a huge amount of money. I wish I could. We have already realised some savings, particularly one of the early projects was in relation to Forth Valley hospital. We have already realised savings of about £6 million over a period of two or three years from Forth Valley. I believe that there is more to be done. If you look at the recent events at Hare Myers hospital, where the cleaning standards fell well below standard, and I do not expect the health board just to re-sign and renew the contract with Hare Myers without giving a very hard time to the PFI contractor. I believe that they brought people up from Coventry to clean Hare Myers hospital. I find that some of the behaviour of the PFI contractor in relation to Hare Myers is totally unacceptable. I think that everybody around this table would find it totally unacceptable. I expect NHS Allanager to hold them to account. I anticipate that Christine McLaughlin is going to say something. Yes, of course. It is good to give you the figures to answer your question. The total spend in this current year, 2014-15, is £229 million on PFI and PPP. The work that the cabinet secretary has just discussed with that specialist team in the short time that they have been up and running have identified what would equate to £26 million in savings over the life of the couple of projects that they are looking at. It should start to give some significant savings, given that these contracts are for long periods of time. Can you also say that, if you look at the detail of those figures, there are particular health boards that have a disproportionate problem. If you look, for example, at Lanarkshire, because both Whishaw and Hare Myers are PFI contracts, the payments for Lanarkshire are of the order of £50 million. Lanarkshire alone accounts for about 25 per cent of all the PFI payments every year in the national health service in Scotland. If you look at Lothian, another board that has got a disproportionately high, mainly because of the royal infirmary, a disproportionately high share of its costs going out in PFI—obviously, 4th valley has as well—there are some health boards that have got relatively few PFI contracts. Clearly, those boards that do have PFI contracts are an additional financial burden on them in very difficult circumstances. I said what I was going to say, the fact that Lanarkshire, as I say, has been a central region list MSP for Lanarkshire, mainly comes into my area. It is quite high proportion of what it has to pay out. He and Myers at the end of the day and Whishaw are exceptional hospitals with exceptional staff in them, but they are costing the people locally in Lanarkshire quite a high proportion. I welcome the savings that you have identified under PPP. I take it that these have quite a number of £229 million per year, but they still have numbers of years to run. Is there any—there is no way that we can convince these people and, as you say, the buyout would be tremendous? It is not just that the end of the contract that has been signed for the end of the contract itself could be problematic to say the least, because you have to look at the legacy from the contract as well. Personally, I would never have signed these in a month of Sundays. Quite frankly, I think that the pure contracts, the here, Myers won the original contract particularly, was a disgrace, but we are landed with them and we have got to deal with the consequences of that. Having said that, I am not just lying down and saying, we will just keep writing the checks. We have a dedicated team and, as Christine said, they have already identified significant savings over the lifetime of the projects, but they have only recently started, so I am expecting more in terms of savings on those PFI contracts in the future, and I expect the boards to take a much more robust approach to both monitoring them and, when things go wrong, making sure that those contractors are dealt with in an appropriate manner and in a very robust manner as well. Colin Smyth, I will take you back on that chart here. Cabinet Secretary, it is really difficult to get a grip of this PFI thing because of the commercial sensitivity that one never sees what the actual contracts are. On the one hand, there is PFI and then there is PPP, which is a bit better than PFI, and then there is NDP, which is claimed to be a better form of PFI, the original PFI. They all include, to a greater or less extent, contracts on maintenance and contracts on cleaning and other things. The other thing is, of course, that the maintenance side is important because the standard contracts, the public sector contracts, do not include maintenance, and the backlog in maintenance has been something that has slipped according to the Audit Scotland report. There are real problems around £96 million of still high-risk maintenance, and some of that is capital that we heard the other day and some of that is revenue. Would it be possible at some point to get some sort of an independent analysis, even given the commercial sensitivity, to look at capital charges on the public sector buildings on the one hand, which are presumably low at the moment because interest rates are low, but worse 6 per cent back in 2000, capital charge versus NDP versus PFI, with all those bits actually spelled out as to what is different. Otherwise, we have no understanding going forward, and our capital budget has been severely cut. That is the thing that suffered most going forward. The amount that we have for public sector capital funding is really tight in that budget. Because of the nature of the contracts, a direct comparison might not be great, but we will certainly look at it and see what we can furnish. We can give you the information that I got in front of me, which is about the unitary charges on all the locations and the length of the contract that is still left. I do not think that we can give you a like-for-like comparison, because they do include different levels of service, so there is not a straight comparison. Even the financing around each steel will be different. We can give you the broad brush differences between what we expect on NDP versus PFI and PPP, if that would be a helpful figure to have. There is a comparison between the NDP and current public sector charges. I presume that the public sector charges are not in the budget. Are they 6 per cent, 4 per cent or what are they going to be? I will give you that, and I will set it out. If we take a general example, it might be a good way to let you see comparable. If we just take a case study and work it through like that, that would be helpful. I think that there is no doubt that the cheapest source of capital funding if you are borrowing is a public world loan sport. Obviously, we will, in the next couple of years, have access to that. It is nice to see that my first question has just been answered. Actually, I will blame Mr Lyle here, if I am good to be honest. The policy regarding the living wage is just trying to get an idea of one that affects the difficulty of producing the living wage within the national health service in itself with the budgetary constraints. What I am unclear of is how does that compare with the colleagues who are doing a similar job in England? In terms of a comparison, it is set out with the living wage and who is God, who does not. Really just a bit more information on the back of that. Obviously, we pay everybody the living wage in the national health service in Scotland, and I think that it is from the last figure. I am doing this from memory, so we will check the figure and get back to you. I am right in saying that nearly 30 per cent of all our employees are on the living wage, in the sense that that is at the end of the scale. I am right in saying that south of the border they do not have a national policy of paying the living wage in the health service. Again, we will double check that and come back to you. However, I would point out that, as well as the living wage, the way that we have applied the pay policy in Scotland has opened up a big difference between our approach in south of the border. For example, the DDRB and the Agenda for Change pay body last year recommended a 1 per cent increase. We paid the 1 per cent increase, and the UK Government decided not to pay the 1 per cent increase. We have kept progression payments, and they are abolishing progression payments. They insisted on it being a two-year deal. We are making it as usual a one-year deal, so they will be reviewed again this year. Of course, we will get the policy of no compulsory redundancies. If you look at the pay differential, for example, if you take nurses, for example, the lowest-grade nurse in Scotland is about £238 this year better off than her equivalent south of the border. A higher-grade nurse will be nearly £1,000 better off than her equivalent south of the border. Because ours is a one-year deal, and I am about to give evidence next week to the pay review body for next year, but they are not doing that south of the border. They are making it a two-year deal, so that gap is likely to increase next year. I do not take any pleasure in saying that, because I feel sorry for nurses and others in the health service south of the border. 1 per cent is not a King's ransom in terms of the amount of increase, but it is the right thing to do as part of a pay constraint policy that allows us to keep a policy of no compulsory redundancy during these very constrained times. We have the balance right in difficult circumstances. A living wage is a key part of that. Within the pay policy, people this year who are on £21,000 or less can get an increase of up to £300 per cent, whereas, if you are over that, it is 1 per cent. Can we have a global sum of what that costs in the National Health Service? The leaked paper of the chief executives of the health board complained about all of this, although it may be well-meaning and agreeable to us politicians of all colours, but we know and it has been listed about what the pension will cost. We maybe do not know about what the on-going 1 per cent will cost, and we do not know what the other measures of no compulsory redundancy will cost. As we remember earlier, the cabinet secretary said that, when we make these decisions as politicians, it means that there is an impact one way or the other in the service and its budget. That is what the poor chief executives have been saying in discussions with the Scottish Government. As well as that, they also complain about the treatment time guarantees. We are all interested in that as a committee about how we move that forward, as Richard Lyle mentioned earlier. We have taken evidence that that has a significant cost, and it would be interesting to understand what that costs to get that other percentage or half a percent or whatever, because that gives it a perspective, which would be important. However, they also worry about other political decisions such as the 24-7 service provision trauma network, which costs them a lot of money in tightening budgets and maintaining hospital beds and nursing and staffing levels, which is a presumed no compulsory redundancy. In that environment, we look at a draft budget that gives them an excellent amount of money, but, of course, the increasing demand, the increasing number of people who are presenting at A and E, and the increasing elderly are there, so we are doing a lot of this to stand still. In the political demands of Government and us politicians, if I have a chance before we finish, I will come back on to the costs of drugs and new treatments that we have focused on, which is a significant amount that we have played a part in. It would be interesting to find out some of the costs associated with those decisions, in the light of the chief executive's health boards complaining of the impact. Two points, convener. First of all, the two biggest increases that we will face next year as a result of the changes to employer contributions in the pension scheme and as a result of the reforms being introduced south of the border. We do not have a final figure on the cost of that, but we are talking about the order of £70 million, potentially. Of course, there are also the national insurance changes as well, which will have a significant impact, but we will, once we get confirmation of those figures to tell you. The pension's impact kicks in from 2015-16. Bores have made a planning assumption of a 2 per cent increase, and that is what is reflected in the paper. We are expecting that final position in relation to the revaluation to be completed by the end of this month, the end of November, so there will be certainty about that cost. We do anticipate it being in that region. The impact from losing the rebate on national insurance is more of a certain figure of 2 per cent, which is factored in to this paper as well, and that kicks in from 2016-17. There are two very significant additional pressures that have not been present in previous years for the boards. I am talking about all the impacts of political decisions down south. I think that the chief executives estimate that in 2016-17 in somewhere around £100 million, so there will be a difference between £70 million or £100 million there for that and the national insurance decisions that this Government makes. The reality is that the costs of the health service are about the people who work in the health service. All of the decisions and impacts that the chief executives make, we can have the global figure about no compulsory redundancy, pensions, the cost floor, the living wage and all of that, the impact. Where is the mitigation and the draft budget for those items to allow people to deliver and change the service? Whenever we will get the final figures, particularly in some of this stuff, we will absolutely provide you with the detail. At the moment, as I said, we can give you some of that, but some of it has still to be finalised in terms of the final estimate. We will provide that. Can I just make a point about the treatment time guarantee? I think that it would be a huge mistake if we just looked at this issue in a very narrow health provider point of view. If somebody is waiting, as was the case 10 years ago, for six months or nine months for an operation and they are off their work for that time, the impact on the economy, let alone the impact on the family budget, is very substantial indeed. Therefore, I do not believe that we can just take in a view of this through a narrow prism of being the health provider. We have to look what is right for the Scottish economy. If you are able to have people have their operations within 12 weeks instead of 12 months, the substantial difference that makes to the wellbeing of the overall economy is very substantial indeed. I do not think that anyone has ever done that exercise in recent times, but I just want to register that thought with the committee. While I do recognise that if, by definition, if you improve the waiting time and 12 weeks is now the treatment time guarantee period, inevitably you have to invest in order to meet that target. However, I think that the Scottish economy, let alone leaving aside the patients who are obviously the main beneficiary, the benefits to the economy in terms of not losing so much output and wealth creation and so on are enormous. I think that we always need to look at the wider picture. I was trying to get at that because what we had spoke about earlier was the targets in general and indeed where there was clinical demand for that and fearful that the outcome would be poorer quality and we would all accept that, but we know when the waiting time targets fail, the political consequences, the cost, the increased use of the private sector, the money flowing out of the national health service—I do not know whether there is a figure, but we have came a long way and many of us sitting round this table were inundated a decade ago about people who could not get an operation. That, in my case, happens very, very—it is disappeared—we touch wood and whatever. There have been tremendous gains there. I am sure that the others would be interested to know about accepting that we have come a long way, much as it is actually cost, much as it is diverting in terms of finance and resources, where we could be creating that space to do something different with that money, whether it be transferring it into the community or whatever. I do not know, but surely it is an area where we should have better understanding not simply about the cost, but the cost as part of that overall pitch. Yes, absolutely. We have that information and we are happy to provide it to the committee convener. Any other questions? Did I pick you up correctly when you said that the £40 million that you announced this morning is out of the £73.5 million? It is not new money, it is within that integrated care fund. That is just to get that clear on the record. The second thing that I have is that in the last budget we had a specific figure for what you would apply to NRAC. I will not ask you for it just now, but could you give us the indication, rather than having to table a question on it? What easier just to send it to you? Easier just to ask you just now and ask you if you could give us that. The third thing is the issue of bed blocking, which is clearly a vexed issue. I mean, we have come a long way since 3000 block beds in 2003 since we began to tackle that programme. Since 2008, when we reached the original six-week target of zero over six weeks, it has not really been sustained. Bits have improved, but the number of bed days, which is, I think, the target that we should be moving to, rather than this week's, because I think that a two-week target is crazy, frankly. I think that it is just not possible. Some will be more. What will happen is many more will be transferred into quotes complex, and therefore they will be taken on to code 9. That is not what we want. We do not want gaming to occur in order to meet the targets. We have been through that once. Can I suggest that we should move to a better occupied bed days target? The real question, convener, is that, given the problems that you outlined of some people having stepped down and some people not, and some people having adequate care home provision, some not like Edinburgh having real problems with care home provision, how do you actually incentivise, how do you provide incentives, but also carrot and stick, so that, in my area, for example, Clackmannanshire, SNP-led, Stirling-Labour-led have almost zero delayed discharges, they have met the four-week target, they have done phenomenally well, but at the Falkirk end they have clearly got serious problems, which impacts on my constituents getting access to 4th Valley Royal Albert hospital. How do you get Falkirk sorted without saying, well, that is because you failed to spend money on this? If we give money to the people who have not performed, you are rewarding bad behaviour. I am not saying that Falkirk is bad behaviour, because I do not know what their problem is, but they have a problem, so how do you deal with this? I think that there is broadly two, you could probably categorise the challenges and the areas where there are challenges into two broad categories. You have got areas like Edinburgh and Aberdeen, where this is a function of the local economy, and that presents itself in a number of ways. In Edinburgh, for example, 25 per cent of people in residential care are self-funders, and, therefore, the attractiveness of local authority placements, which is about half the going rate for self-funders, is, obviously, a factor that is limiting the number of places available for local authorities to place people. We need a strategic solution to that, and it is one of the reasons why Lothian is struggling to me to say any turnaround time, quite frankly. It is not because—I say this, convener—if you actually look at the turnaround time within A&E departments, according to the Royal College of Emergency Medicine, and take out the period when, after they have been treated waiting for a bed, they are actually turned around very quickly, relatively speaking, within A&E. The bit that is adding on and causing them not to hit the target is the time that they are waiting to be placed in a bed and a ward very often. That is very often because the bed is not there because it delayed discharges, or because the daily discharge profile is not good enough. Those are the two main contributing factors. In Edinburgh and in Aberdeen, in particular, there are strategic issues. The care sector is finding it very difficult to get workers, because the wages are low. Quite frankly, in Aberdeen, you get more money for filling shelves for a supermarket than what you do for working in a care home. We are working with COSLA, because we recognise—this is public—we recognise that we are not paying enough for residential care. We recognise the need for the living wage throughout the social care sector, et cetera, et cetera, et cetera. We are doing a similar exercise on home care at the present time, because many of the issues are absolutely the same issues. Category 1 would be the lights of Edinburgh and Aberdeen where you have a strategic problem, and we need to have a strategic solution to that, because no matter how much we try, those are buoyant economies and the consequences of the buoyant economy have present real problems in terms of getting the people to deliver either residential care or home care. Then you have the second category, where I think it is an issue of management of funding, the lack of integration, the lack of a step-down facility and a whole range of other things. That category could probably be more easily solved. I will be expecting the strategic plans presented by the integration boards all to have very clear plans to deal with this problem. Where we have had integration for a long number of years, such as West Lothian, we do not have to lead discharges, because the whole thing is joined up. They also have a step-down, step-up facility, and it is one of the reasons why they do not have delayed discharges. I can tell you now that the delayed discharge, the very significant increase in recent months, is going to have a negative impact on the A&E turn around times, not because of poor performance in the A&E departments, but because of the knock-on impact on the availability of beds and wards. I will be absolutely up front about that. Music to the committee's ears about your discussions with COSLA and the living wage for care workers and indeed training and the quality of your great stuff. I look forward to hearing all about that. Richard Lyle is coming back in. I will supplementary. Cabinet Secretary, as you know, I had extensive years as a local authority councillor. I will not mention how many years bore everybody. I am a very, very good one, if I may say so. Thank you very much, cabinet secretary. You do a good job, too. The point that happened in many local authorities is that they reduced their care homes substantially in my own authority, North Lanarkshire Stroke Model District. They closed a care home in my own ward numerous years ago, which 20-30 people were in. I totally agree with you that, in order to get people who want to get out of the hospital—they do not want to be there once they are well—to get them into a situation in which there is a half-way house step-up, step-down using the terminology, I totally agree. Are we taking steps, along with the cabinet secretary and other ministers, to look at how we can help councils in order to get the situation along with what has been brought in in the new legislation? Two things. First of all, I have made available additional £10 million in two tranches of £5 million to help with the immediate issue, but I am not going to make that available every year. That is to deal with the immediate situation to help councils over what they perceive to be a particularly difficult period. Secondly, I have a meeting this week with Mr Swinney and Mr Mackay precisely on this point, because clearly the social care budget is part of the local government settlement. As well as the bilateral discussions that we are having with individual councils to try to help them through the challenges that they are finding in dealing with this issue, I am talking to Mr Swinney and Mr Mackay about what else we can do as a government to try to significantly bring under control the delayed discharges issue. It has a substantial knock-on impact, particularly on the patients. If you are ready for medical discharge and your discharge is delayed for whatever reason, there is very clear clinical evidence that within a 72-hour period, your condition starts to reverse and deteriorate. Clearly, that is the last thing that we want to happen. I am regarding this as one of my top immediate priorities to try to work with the local authorities to get this issue resolved. I am sure that many local authorities will also welcome that statement. As long as they know that I am getting nemy and money? We wish you well that I am getting money out of Mr Mackay and Mr Swinney anyway, because it is much needed in our communities. Aileen, do you want to ask that climate change question? I have a lot of questions, but you have quite a few to do so. Thank you. Final question. The NHS board survey that was conducted by the committee found that there was a range of examples of how NHS Scotland's sustainable development strategy had influenced the budget decisions. The question relates to asking around to do the NHS boards need to be doing anything further to achieve the climate change targets. Does there need to be any sort of co-ordinated action that is taken by the Government as regards the health budget to achieve the climate change targets? There is actually Mike Bankster, who is Christine's colleague in the finance department, who is leading this for the Scottish Government and who is working with all the health boards, particularly on the energy front, the total energy bill for the national health services of the order of £70 million a year. We would like to be able to reduce that, but not just because of the cost savings, but because we want more efficient use of energy throughout our estate. If you look at the estate strategy that was published last year and the update is due, I think, before Christmas, one of the key sections is the initiatives that we are taking in terms of improving our use of energy and extending the use of renewable energy resources within the national health service. There are quite a number of examples of where we are doing that, and, indeed, where we can, we are keen to be part of district heating systems and the like. We will not just do it in isolation, but we are doing it as part and parcel of the wider Scottish Government effort to improve energy efficiency and extend the use of renewable energy to replace fossil fuel energy. That is great. Thank you very much. That is a very good question. I have one final question in terms of the interest of the committee. This is the third final question. This is the third one, just when you think you get to go. We spent a lot of time, cabinet secretary, with you on the funding of new medicines for end-of-life and rare diseases. You announced, I think, 2013, £20 million and £15 million and £16 million and £40 million. We know also—we play a part in this—we have created a pressure on the health service that one of the risk factors identified to us in previous evidence was the increasing drugs bill. We know that, I think, pharmacies and hospitals are increasing. That is increasing by around £10 million per year. The £40 million that you have announced will be on top of that. How did you arrive at the £40 million figure? Do you see this as a one-off or do you see this accumulating over the next couple of years? It has been suggested that it could be in £16 million and £80 million, because this will provide for x-amount of patients with new medicines, but there will be new medicines coming on top of that. How do you see this developing? As I said to the nine million earlier when she asked me, more or less the same question. The £40 million was our estimate of what would be required to fulfil the gap that the new medicines fund is designed to fill. I know that we had some estimates to the committee from the SMC some time ago of £70 million. As it turned out, our estimates are much nearer £40 million than £70 million. It so happens that we are estimating something of the order of £40 million of the PPRS money, which is new money, coming to the Scottish Government under the prescription price regulatory system. We are using that money to fund the new medicines fund. The new medicines fund will be a permanent feature of the national health service in Scotland, but the reason that I have only announced funding up until 2016 is that we do not know yet what the funding will be that we will be able to receive from the PPRS beyond 2016. We do not know what the overall Scottish Government budget will be beyond 2016-17. The new medicines fund will be a permanent feature, but I cannot realistically set aside money until I get the information on how much money will be available beyond 2016. When the prescribing was identified as a risk factor at that point in time, it was explained to us by the Government and others that the PBRS scheme would be medicines coming off a licence or however we would describe that, would reduce the prescribing demand on the health service and the health boards. It will not, clearly now, because it is not going to the boards. The reductions in what we pay for for those prescribed medicines are not going into the health boards and their budgets in hospital pharmacies are going up by increasing by £10 million a year on average. The risk there still exists for the health boards about this increasing bill. Before we set up the fund initially of £20 million, the bill for some of the medicines that were made available as a result of the IPTR process, for example, were picked up by the boards. There will be an element where what was previously picked up by boards a number of years ago is now picked up by the new medicines fund, although it is difficult at the moment to be precise about exactly how much of the £40 million will fall into that category. The second thing, convener, is that we are engaging in looking at even greater control over the prescriptions budget overall. The budget's bill is running at roughly £1.3 billion a year for the National Health Service in Scotland. As you know, the Auditor General produced a report a few months ago. She suggested, with a number of changes, that we could save £26 million. I think that from memory was a suggested figure a year. We are working through the recommendations in that report, plus some ideas of our own, to try to get to a position where we get better control on prescribing at every level. From that, what? Exactly. Exactly. We would retain that money. Exactly. Absolutely. You see the £40 million as something that the fund is sitting there, which will not grow but will be capped effectively to 2016. Is that so? Well, at the moment, we think that we will not go above £40 million. Obviously, if there was an unmet demand, we would need to decide how we would fund that, but we are fairly comfortable that setting aside that £40 million will actually be enough to provide for the demand around it. If I pick forth Valleys, they did an exercise last year on improving the control of dispensing of statins. As a result of that, just on statins alone, they reckon that in future they are going to save £6 million a year as a result of the new methods that they have introduced. I will just pick that as an example. That is not something—I think that there is quite a lot of potential still in savings on the drugs bill. Indeed, if every health board was as efficient at managing its drugs bill as the best, we would save tens of millions of pounds on the drugs bill every year, and that is really what we are trying to get to. I will explain that. We have done quite a lot of work to understand the scenarios around the costs of the new SMC process, and it is not an absolute figure. It depends on your assumptions, obviously. That is why the figures that we have got differ from the original estimates that you received. The £40 million makes sense because that is also what we are anticipating in terms of receipts. It is also what we believe to be a realistic estimate of the cost in this year, but it may be higher and it may be lower. We will look at that now that we have got the new process in place, particularly around resubmissions and what happens there. We have got a detailed process in place to identify the impact of the costs for geared up to get all the information from the boards on a regular basis so that quarterly we can report on actual costs against the new process. It is similar to working for the £40 million that can be provided to the committee. We will be able to collate that information on a quarterly basis and see what the actual spend is. That is what will allow us to look both into 2015-16 and see how realistic that is against the £40 million, but all that money will then go out to the boards based on the spend. I do not think that there are any other questions. Cabinet Secretary, McLaughlin, thank you very much for being with us in the time you spent with us. Pleasure, convener. Thank you very much. We will suspend at this point. We are going into private. We agreed that.