 Good morning and welcome to the 29th meeting of the Health, Social Care and Sport Committee in 2023. I've received apologies from David Torrance and James Dornan will be joining us as a substitute. The first item on our agenda is to decide whether to take items 46 in private. Are members agreed? Thank you. The second item on our agenda is an update from the minister for social care, mental wellbeing and sport on the National Care Service Scotland bill. For this morning's session, I welcome to the meeting Mary Todd, Minister for Social Care, Mental Wellbeing and Sport, Donna Bell, director of social care and national care service development and Rachel McGrew, deputy director of social care and national care service development and from the Scottish Government. I invite the minister to make a brief opening statement. Thank you very much for inviting me to provide an update on the NCS bill. During the summer, we've used the time to respond to stakeholder concerns. We've agreed proposed changes to the overarching structure of the NCS, which will help to achieve our ambition of improving quality and consistency of social services. We've also carried out extensive co-design engagement across Scotland to understand how to achieve the change that is needed. After being out and about over the summer speaking with people, I know more than ever that the status quo is not an option. We must act decisively so that people can have the improvements that they need as quickly as possible. We must make wise decisions in a new fiscal environment where resources are under pressure. That is not an easy task. However, we are absolutely committed to getting it right by listening to the voices of experience. I would like to outline how we propose to go forward having listened carefully to those voices. In my recent letter to the committee, I described our extensive summer programme of local co-design activity. We held regional events across Scotland and online. Hundreds of people participated in sharing valuable and diverse feedback on the NCS. I attended several events in person, and I would like to take this opportunity to thank everyone wholeheartedly for sharing their experiences and knowledge. We have now published our analysis of those events. Those will shape both our thinking going forward and the second NCS national forum on 30 October. Our other major discussions over summer have been with COSLA, the NHS and trade unions. We have reached initial consensus on a partnership approach with COSLA in July, which will provide shared legal accountability for integrated health and social care services. Those discussions are still continuing, developing more detail that will inform our proposed amendments to the bill. It is important that we have effective national oversight and governance to drive consistency and improved outcomes for the people who access support. The proposed NCS national board will provide that. At local level, local government and NHS boards will retain statutory delivery functions and the staff and assets to deliver services. We are considering how local integration structures can be reformed and strengthened as part of the NCS. Additionally, we are discussing the bill and current challenges in social care regularly with trade unions. Although we are limited in legislating on employment, we are committed to promoting fair work as far as possible through ethical commissioning and procurement. We will also provide funding to increase the pay of social care workers and improve workforce planning, practice and culture. We will also take the trade union views on issues such as workforce representation into account when designing the national board and local delivery. In summary, it has been a very busy summer with many productive discussions and positive developments. I hope that that is a useful overview before our discussion. Thank you very much minister and thank you for attending committee today. As you said, it has been a very busy summer with a lot of engagement across the country. Can you expand a little bit on some of what you said in your opening statement about the impact that the accord with COSLA will have on shared accountability and what impact that will have on the national care service and the relevant provisions in the bill? The shared accountability is a couple of important things to draw out about that. It is shared accountability rather than joint accountability. That is a significant distinction because we have different groups to whom we are accountable. As ministers, we are accountable to the country. Local authorities are accountable only to the local authority that they represent and the national health service is accountable to the board. We all have different groups to whom we are accountable. However, if we share that accountability, we get really good coverage and really good oversight of the country. I think that the three of us together will definitely be able to deliver an impact in terms of delivery of better standards and better qualities. I think that the national care board and we are still working out the detail. I do not think that it is just going to be the three of us. I think that there will be more people around that table. I would expect there probably to be an independent chair. I personally think that the voice of lived experience is absolutely vital on that board. I think that representation for the workforce, representation from the national social work agency, those are the things that will give that board teeth and make sure that it delivers an impact. I have heard many people criticise that it is just the status quo, but it is different. At the moment, I have no control over the social care system. I am held to account day in, day out for things over which I have no control over. In future, Scottish Government ministers will have some control. They will share that with a national body who will absolutely ensure that we deliver improved standards. I suppose that you have covered a little bit of my next question. This is an issue that has been raised with me in MSP. I am sure that, as Minister, individuals are saying that they are disappointed that accountability will be shared, because that was one of the recommendations of the report that said that there would be ministerial responsibility. I am concerned that, if that responsibility and accountability are shared, it will continue the existing postcode lotteries as people see it of access to care services. How will you ensure that that is not the case? I absolutely hear that criticism loud and clear. I hear it very directly because we are engaging so closely with people with lived experience of access and care. Undoubtedly, there are many people for whom access has been traumatic and disappointing. They are absolutely clear that change is required. I am absolutely clear that change is required as well. As I said, the shared accountability that we foresee will give ministers control over the system, although ensuring that delivery locally is still done by the local democratically elected body. I think that that is probably the best combination. It is really important that that board has power to take action when there is system delivery failure. I am determined to reassure people that it will have sufficient power to take action when it needs to. We are envisaging something similar to the arrangements that are in place for health boards at the moment, where there can be interventions if there are challenges and an escalation of intervention. We are envisaging something similar for the national care service, and that board will have the power to intervene. What would become of health and social care partnerships and how they would relate to the national care board in terms of governance? We are still in the thick of discussing the local governance arrangements. I might ask officials to come in a little bit in case I have missed anything in all the answers that I have given, but I would envisage that the structures that are already there will be strengthened. What we have at the moment is quite a disparate pattern of integration, which is one of the reasons that we have that postcode lottery. In some parts of the country, there is more integration than others, and that probably is not serving as particularly well. I think that there will be a move towards more integration all over the country, and the integrated joint boards and the HSCPs. The structure will evolve and probably strengthen to oversee the local delivery of social care. I think that there is a distinction to be made between the integration joint board and the health and social care partnership, because the integration joint board obviously has a legal foundation, whereas the health and social care partnership is essentially a way of working. Sometimes that creates a bit of confusion, so one of the things that we are quite keen to do is bring a bit of clarity around those accountabilities and how all that works as we go along. Do you want to bring in any other official here? No, it is just to reiterate what the minister said, is that the discussions are under way to work out exactly how we can strengthen local integration under the model. In the programme for government, there was a pledge to set £12 an hour as a minimum rate of pay for all social care and support staff. How will that be implemented effectively? Over the last number of years, we have effectively introduced a floor level for payment of social care staff, so we have introduced that nationally. We have done that by providing the funding to ensure that that can be passed on to staff. I think that we will manage to do that effectively. Again, this time, using those same mechanisms that we have used for a number of years, I am absolutely delighted that we are delivering on that commitment. I know, as ever, that people are pushing for more and would like to see even better pay in social care. I absolutely am delighted that we are delivering. Given the financial constraints that we are facing as a nation, I am delighted that we are delivering. I am delighted that we are setting a path where we are seeing, year on year, that significant improvement in pay to social care staff, because that is one of the really important things that we need to do to strengthen the system as a whole. How can ethical commissioning change the nature of contract competition? One of the challenges that we have in the Scottish Government is that we do not have control over employment law. There are many changes that we would like to see in the employment of social care staff in the sector, and we do not have the powers to directly intervene. Ethical commissioning gives us some power to ensure that, where we are using public money, staff are treated well. That is an important part of what we are hoping to achieve with the national care service. When I think about the change that we are trying to achieve, the two groups of people I have in mind day in, day out are the people who are accessing care, from whom I hear just how difficult that can be every day, and the people who are working in social care. I am pretty confident that ethical commissioning gives us a tool with which to improve their pay and conditions and voice and build in some fair work principles into the procurement process. I am not sure, Donna, if you want to say a little bit more about that. I am happy to do so. Current procurement legislation already provides the opportunity for ethical commissioning. The national care service bill has introduced places duties on ministers and on care boards to produce ethical commissioning strategies as part of their strategic plans, which I think is a key part of implementation. There will be an opportunity through that to support consistency and enable us really to focus on those important issues that the minister has already picked up. We do still have some detail to work through on exactly what those ethical commissioning strategies will look like, the expectations that sit behind them and implementation. I think that it is a very important step towards embedding that in all of our practice in social care and beyond. I go on to move to Carol Mawkin, who is joining us remotely. I am interested in just a couple of points following on from Evelyn Tweed. I am interested if you can just give us some idea of how in the future sectoral bargaining might operate within the sector across the public and the third sector and the private sector. Sectoral bargaining is probably the toughest area to deliver and there is a lot of work going on in that area. Usually it is fairly straightforward once you define the sector, but even defining the sector has proved difficult in that sphere. It is very complex. The way that care operates in Scotland is pretty complex. Generally, in sectoral bargaining, there is discussion between a group of employees and an employer or two. There are clearly multiple employers in social care and then there is also government who have an interest because we provide a lot of the money to pay for commission places and to increase wages. There are more people around the table than there would normally be in a straightforward case of sectoral bargaining. We are getting into the detail of it now. We have approached a couple of academics on the recommendation of some of the trade unions that we work with and we have involved them to try to help us to unlock those discussions and make progress. I am reasonably confident that we will make progress on the area of sectoral bargaining and I think that that absolutely will be crucial to the delivery of fair work in the future. Lovely. Thanks very much. It was very helpful and also the discussion that you had about engaging the trade unions. I am assuming that you will continue to work with the trade unions as we go through the national care service bill. I am interested in my last question, if you do not mind, to what extent and in what ways do you expect the new accord with COSLA on the shared legal accountability in addressing the concerns of the trade unions in the bill? How do you see that working as we move towards that agreement in the national care service? You are absolutely right. The trade unions will be crucial to the development of the national care service and I spent a lot of time over summer working with them and I would expect that to continue. More than that, I have said a number of times, one of the reasons I think that the social care workforce is so disadvantaged is because it is largely female, 83 per cent female and barely unionised, so less than 19 per cent unionisation, so I would like to see a stronger role for unionisation within the workforce as well as me working with the unions to develop the national care service. In terms of the shared agreement, I talked before about this national care board. The national care board will be broader than just ministers, local authority representatives and the NHS representatives. I would expect the voice of employees, the voice of people who work in social care to be at that table as well, so I would envisage an on-going space at the table for dialogue with them. I think that the national social work agency, while it is not a union, it is a professional organisation that we envisage, will again be a strong voice for social workers in the national care service. Social workers are absolutely key to the effective delivery of the ambition that we have set out in this. Again, there will be a strong role for people who work in the sector, not just in the development of the national care service but in the on-going delivery and national governance of that delivery. As I said, I cannot commit to these things yet because we are still discussing it. What I am laying out today is how I envisage that taking shape. Thank you, convener. I am picking up on that theme of engagement with trade unions and I declare an interest as a member of Unison. Do you minister envisage that there will be any changes, any specific changes to the contents of the national care service bill following your on-going discussions with the trade unions? I think that it feels best to answer that. We are working through amendments and I cannot recall how many questions we received from the unions, but there were quite a lot, which is totally reasonable. We have been working through those with them and working through what amendments we might need to make. We have not reached any conclusions on that at the moment, but that dialogue is under way. I am interested in the co-design process and the regional events that took place over the summer, because I know that for me there was an event in Stranraer and there was one in Hoik. You focus on rural and urban, so I am interested in a little bit more information about the co-design process and whether that was different from other processes that had taken place previously. Generally, when you go out to consult, you have a set of proposals on the table. This has been one of the criticisms of the entirety of the processes that there is not enough meat on the bones when we have gone out to speak to people. Usually, you have a set of proposals and you say to them, do you like this or do you not like that. We have taken a step back from that. We are in a process of co-design, so we spend a great deal of time understanding what the current situation is and trying to imagine a different way of doing things that would absolutely deliver better. It is a step back from consultation. What it delivers us is the voice of lived experience right at the heart of the design of the national care service. I think that that is really important. I do not envisage that having a hard stop at the end of the bill being delivered, I would envisage the voice of lived experience continuing to be a strong part of how the national care service evolves. It is going to help us to get the policy right in the first place and it is going to help us to deliver it to the ambition that we are given. Is that sufficiently clear for you or do you want me to bring in officials with a little bit more detail? Yes, I am interested in the fact that we have taken our step right back to involve people right at the very beginning, because that seems to be valuable in involving people with the wide range of experience. We have heard of the support that is required right across the social care spectrum. I probably need to remind everybody that I am a registered nurse and I spent time over the summer visiting social care delivery people at Stewart Recair and Castle Douglas. Their work is varied and very skilled and competent in delivering care for people in their homes. I am keen to make sure that people understand what the co-design process is, because I know that people just assume co-design and co-production as the same thing when it is not. Did that come out in any of the consultation process about this as co-design and it is not co-production? I am happy to say a wee bit more about that. As the minister says, the response from people was fantastic. We had over 500 people at the in-person events and we had hundreds at the online events too, so I absolutely thank you to those people for giving up their time. Certainly the people that I spoke to found it very valuable but quite a different process, because we were not presenting, here are some proposals, do you like them or not, it was really getting into the depth of their lived experience and what their understanding of how the system works for them at the moment. We had the five co-design themes about keeping care support local, information sharing, making sure that my voice is heard, realising rights and responsibilities and valuing the workforce. It is also important to say that when we talk about lived experience, we are talking about the experience of people who work in the sector as well as those who are receiving support or services. The reports were published last week and we can send on the link to those to the committee if that would be a helpful thing to do, convener. There is some excellent insight in there about how people feel about the way they engage with services, lots of really helpful information and insight that, as the minister has said, will help us inform the delivery of the bill but also the delivery of the national care service more broadly. I could go into lots of detail about this but I will not, but I am very happy to answer any further questions. Just looking at the Government's website, there is lots of information from the six reports and the format that it has. There is accessibility for the format as well. It is pretty comprehensive the reports that are here and I will need to read them in more detail. I appreciate that. For me, what the co-design delivers is a sense of empowerment. It really is about empowering people. It is handing the power over to them to say, if you were in charge, what would you do? How would you do it? How would you design a service? We hear from people time and time again where things go wrong and how difficult that feels. It is really about making sure that we get it right from the conception stage rather than just rubbing the edges off delivery. I have heard from people who are involved that it feels very different. They do say to me that we have been saying these things for years. It is not like we are saying anything new. The difference is that the system, including all of us, is now listening. I think that that is a really important part of the process. I have heard over the past few years about how people say that we want to work with people and help to support their care with them and not do stuff to them. We are making progress on that language as far as working with people rather than doing stuff to them. I think that the very first time I met the social covenant group, they corrected my language. I made the rookie error of talking about person-centred care and they said, excuse me, minister person led. So they absolutely want to be in charge. It is a really useful lesson for me early on to listen very carefully to what they are saying and to always make sure that they are in charge and that, as independent as they can possibly be, that is part of the purpose of designing the bill this way. It would be helpful to the committee to receive that additional information from yourself, Ms Bell, or from the minister. I will move to Paul Sweeney. Thank you, convener. Thanks to the panel and the minister for attending today. I think that there has been quite a bit of confusion about what co-design means and how it does differ from consultation. Could you clarify exactly how much influence the learnings from this summer's forum events will have? Are they geared towards how the national care service will operate in terms of the processes and procedures or the design of individual services within specific areas or in the territorial boards? I can maybe just give an example to help bring co-design to life, is probably the work that we've done over the summer under the realising rights and responsibilities design theme, which obviously we know we're committed to a charter of rights and responsibilities for people. We have been taking that draft charter out to individuals in the sessions. They have been helping us to design it to make sure that it's meaningful to them, that they feel that it has teeth, and that is direct working-together designing. That is a principle that we're also looking to do in the development of the workforce charter as well. So co-design is getting people around the table together, working together to help find the solution, which I think is quite different to the traditional consultation approach. So just in terms of the framing of the work that we're doing just now, as my colleague has said, areas like the workforce charter and informing the bill and areas like the in due course, the national board, we're not at the point where we are doing any service design at all. As Ms Todd has said, as we move forward into the implementation of the national care service, there will be a strong expectation that co-design will form part of the future of service design in the national care service in Scotland. Does that help, Mr Shwney? I think it does, and it has brought us neatly on to that point about the charter being a critical point of, you know, it will be the lunchpin of how this service will operate and will be its underpinning. There was a bit of dispute previously about having that charter on the face of the bill. Will that be the opportunity now, given that there has been a draft produced and out to consultation as part of this co-design process? Will Parliament be able to actually have sight of that and codify it, if you like, on the face of the bill, both the NCS charter and the workforce charters at the intent of the Government? I think the expectation is that we should have a form of the draft charter to share with the committee early 2024, so early next year. I think the preference would be because it is co-design and co-design is very much an ongoing process, and to make sure that we have the ability for that to be iterative and for people to work with us so that it wouldn't be enshrined in the primary legislation would be the intention, but we definitely would be looking to share a draft with the committee as soon as we think that it is an appropriate format. At what point does the charter then become stabilised as a sort of codified document? Is that the intent? I know that you are saying that it is a fluid process, but clearly at some point it is going to have to be finalised and agreed and ratified by all the stakeholders. What point do you envisage that happening? We are currently in the sense-making phase of the co-design process, so we will be working through the different phases of that co-design process. At a point when we feel that we have reached that agreement as a solid status, we would look to codify it, but we recognise that it would be a document that we would want to review regularly and make sure that it is not something that is set aside because we will need to make sure that it is meaningful. That is one of the things about co-design, and one of the reasons that we have enshrined it as a principle within the bill is that it is an on-going commitment of the national care service through a process of continuous improvement that we would check such things as the charter. Could it be an option to have the initial codified version on the face of the bill, even if it was introduced at stage 3, and then with the provisions within the bill that it could be amended through delegated powers in the future, at least it gives it a sort of focus within the bill. I know that the NHS charter is very much at the focus of the NHS acts. It would be quite nice to have it as a feature in the primary legislation in that sense. Is that something that the Government might consider? We will certainly consider it. I won't give a promise here today. We will probably need to discuss that with drafters and get various technical guidance on whether that is a possibility, but we will certainly consider it and take that away and get back to you about whether that is a possibility or not. Just also on the co-design process. I know that there have been a lot of regional events trying to make sure that there is geographic coverage, but just also what other methods did you undertake to ensure that as many different stakeholders, particularly underrepresented voices, were given a sufficient opportunity to input to the process? I will come to you in a second. As well as all of the regional events over the summer, because of popular demand, we added another three regional events since then. We had a national event at the end of October. We also held online events for those people who could not attend in person. We have commissioned some specific work with specific partners to go out and reach those groups that we felt that, when we looked at the information that was coming in, we felt that we did not have 100 per cent coverage, so we have commissioned some specific work from specific partners on that front. I will give you a little bit. I was just going to mention the work that we have done to follow up with those seldom heard voices, because we want to make sure that we maximise the reach of that work and will continue to do that as we go along. If we review the evidence that we are seeing coming back from the co-design process and seeing that there are groups that are either underrepresented or not represented at all, we are proactively seeking input from people. Quite a lot of the time, doing that through colleagues in the third sector is a really good way to do that, so we have provided grants to a few organisations to provide some supported engagement with the co-design process. I am going to stay with you to lead on the next theme. We are moving on to the proposed delivery of services, and we know that there is a postcode lottery of access to social care services. Within the new structure of the national care service, how do the Scottish Government plan to improve access? That will be crucial to the success of the delivery, and that is how we improve access. We are aware at the moment, and we will all pour over, particularly coming into winter, the figures around delayed discharge. We are less good at capturing, but equally important is the level of unmet need that we know is in the community for people seeking care packages who are being assessed and unable to get them. We know that accessibility at every step is a challenge. One of the challenges that we face is that there are different levels of integration around the country. As I said, that level makes it difficult to know where. Services are falling between different—sometimes what we think is happening is that services are falling between the cracks in terms of accountability between different models of design. We are absolutely determined to—I see the national care service as the natural next step in integration, so that is about further integration. We see around the country different models of integration in some parts of the country. Mental health is included, and in other parts of the country it is not. That gives rise to some of the postcode lottery and some of the challenge in taking steps to improve accessibility. We will be looking at whether that serves the nation well and probably the thing is to improve integration in every part of the country. The national social work agency will bring forward national standards and I think that that will be an important part about improving delivery and making sure that everywhere operates to the same national standard. It will give protection, I think, to individual social workers so that they know what they need to do at each step of the way in their jobs, and I think that that is really important. That national board, as I said, I mean I am pretty determined that it is going to have teeth, so it will not just be there for decoration, it will absolutely be there to take an overview and take action if there is service delivery failure in any part of the country, so where problems arise, that national care board will be able to take action to correct any problems. One of the things that I think will be really important, and we have spoken about it, I think, at the last time of that committee as well, there is currently just reported a review on independent inspection and scrutiny. I think that that is providing us with, and we have still to reflect and respond to that as a Government, but I think that that will provide us with another lever to pull to improve the situation and to improve the standards nationally. I think that it is a really important part of the process getting that inspection and scrutiny process right, and I suppose that one of the aims is to shift from what is perceived as a punitive system where people are, you know, where there is reputational damage, if things are falling short to a more supportive system, where there is an ethos of continuous improvement and where support is available easily to try to improve standards where they are found to fall short. I think that that point about continuous improvement and benchmarking and bringing everyone up to the highest common denominator is a helpful insight to the aspirations of the Government in this respect, but there is an issue that was brought up in discussion with the Cabinet Secretary when the talk committee earlier this month scrapping non-residential care charges by 2026 wasn't necessarily going to be achievable anymore and it certainly wasn't going to be a key priority going forward. How does the Government propose to address that postcode lottery without scrapping non-residential care charges? Is this something that has been considered within the development of the national care service? So, as far as I know that commitment still stands, it remains. We are in exceptionally difficult fiscal times at the moment and I don't think there's ever been a more challenging time to be in government in terms of finding the money to deliver the commitments that we have made, but I'm kind of operating on a procedural apprehended basis, so nobody has told me that we're not doing that. We are, as far as I am concerned, definitely doing it. Thank you very much, convener, and good morning minister. You have touched on some of this already, but I'm just wondering if you can see what it is that the Scottish Government is doing to support local authorities in health and social care partnerships with the current and immediate issues in social care and support provision, so, for example, staffing and capacity? So, there's a lot of work. Obviously, the delivery of the £12 an hour is key. I think that that is going to help, but it's not everything, so there's work going on across the board to improve, as well as pay conditions, focusing initially on maternity leave and sick pay. That's one of the fair work strands. There's work going on with the SCCC and NEST to try to provide educational opportunities to support the workforce so that when people come into the social care workforce, they feel well supported, they know what it is they need to do, and they have clear pathways to improve and clear pathways to further careers should they wish to study and move on. There is, as I say, a great deal of work going on across the board, and not all of it requires primary legislation for it to happen. I think that some of it we can deliver without the primary legislation. I do think that a transformative change is required if we are to achieve one of the things that I hope we will achieve is an increase in the status of social care. I would love it if, in Scotland, we were talking not just about social care as something that helps the NHS when it's in trouble or harms the NHS when it's not functioning right, but valued it in its own right and its inherent ability to change people's lives. Social care changes totally transforms the lives of those people who are able to access it. It transforms their family lives. I meet day in day out carers who are stretched to the limit trying to cope with the situations that they are in. An effective social care system takes the burden off families, it contributes to communities and it contributes to the economy. We are quite keen to try to start talking. We talk a lot about the cost of social care, we don't talk quite so much about the value of social care. I am determined to move the conversation on to the value. On a very regular basis, I meet people who are struggling to work because of their caring responsibilities. If we get social care working right, it will have an impact on the economy. If we can articulate that better, we will stop thinking quite so much about the cost and start recognising the value of what we do with the NHS. You are absolutely right. I am sure that we can all agree on how valuable it is in those pathways that you spoke about, which is so important. I would like to ask you about the end of life, because not everyone will recover. A substantial proportion of the current health and social care budgets is spent on caring for people approaching the end of life. At a previous committee, Mark Heazlewood, chief executive of the Scottish Partnership for palliative care called for changes to the principles of the bill to include the end of life care. My question is how will the national care service be developed to respond to the growing needs for palliative and end-of-life care? How are co-design forums informing us on that? I do not know if you can give more detail. I would have to say that I have not been asked very much about palliative care, although the reality is that the vast majority of people who go into a care home will go into the care home at the end of their lives and will pass away within around an 18-month period. It is there, but it is not up-front. I will let Donna talk a little bit more. The amount of hospital admissions is there, but we are always talking about taking down admissions. Obviously, that is something that is not quite so movable. I am really keen. I am absolutely determined, particularly because of where I live. The geography of where I live is very challenging for social care. We do not have a care home in the village that I live in. If you are unable to manage independently in your home in my village, you will have to move away from your community, from your family to access care, probably on the other coast. That is the reality for people in the Highlands. One of the reasons for our focus on the national care service is to absolutely shift care upstream and to try to get into that early intervention and prevention end of things to support people to live independently and healthily at home for as long as possible before care is needed is about enabling people to grow old and frail and potentially die in their own communities. We are determined to deliver that. I will pass over to Donna for a bit more detail on palliative care. We have engaged very broadly through the co-design process, particularly with people who have looked after relatives, who have received palliative care. What we have avoided doing is naming multiple conditions or multiple situations on the face of the bill because there are many, many circumstances that people will find themselves in. I think that the importance of the charter is crucial here so that aspects around dignity, respect and equalities are all going to be critical, particularly in the case of palliative care. What we would want to do is ensure that the aspects of the charter that we want to draw out can be applied across all aspects of people's care, not just specific to palliative care but certainly they would have a clear role in ensuring that people have the dignity and the care that they need as they go through the palliative process. I hope that that answers your question just in terms of the face of the bill, and there are other mechanisms to draw all of that in. I am very happy to look at that and to pick up again with Mark on palliative care. Are you finding that you are getting that feedback to help inform it through the national care service forums? Is there more work to be done in that area? There is always going to be more work to be done. We are getting some really good feedback, particularly on the charter, about how those rights can be made to feel real, how they are very clear. One of the key things is to make sure that it is unambiguous and that people can really see what their rights are, how they can hold partners and the accountable bodies to account for those rights. I think that we are getting that feedback. Again, as the minister already said, we will continue to do that engagement. We have not just the individual lived experience panel of experts, but we do have the stakeholder register, which has over 300 organisations included in that. I am very happy to pick that up again. Thank you, convener. This section is the current status of social care, so good morning, minister. The national care service will cost upwards of £1.3 billion and is already overdue. You have said this morning, minister, that there is a great deal of work going on, but you also said that you currently have no control over social care. My question is, what are you able to do in the interim period to support the social care provision that is going on right now? One thing that we are doing is putting a lot of extra money in. We made a commitment during this term of Parliament to increase the amount that we spend on social care by a quarter. That would be £840 million going into social care, and we are already at £800 million, so we are ahead of trajectory on that. We are vastly increasing the amount of money that we put into social care. I think that Derek Feely was very clear. If I think that what you are asking is correct, it is what should we be pursuing, structural change at a time when the system is under so much pressure. Derek Feely was very clear that if we just keep doing the same thing again and again and again, we will just keep getting the same outcome. We are very clear that the system is not working as we would want it for those people who are accessing care at the moment, so we need that systematic change. We need that whole system change. We need a transformational change to be delivered in order to meet the aspirations of the nation, frankly. Minister, the question is what are you doing now. That is £840 million, which is great that that is being spent on it. What is that going on? Things like increased wages would be one thing that we have done. We have drastically increased the amount of money that people working in social care get paid. Over the past couple of years, it is over 14 per cent wage rise that they have had, so that is one clear thing that is improvement that will be felt by everyone working in social care. People working in social care in Scotland are now paid more than their counterparts all over the UK. There is more to be done, but I think that that sets us on a clear path and that is what I would expect to do, to do more of that. That pay, you are saying, that £840 million, that is going in the public sector and the private sector increases. Yes, because we have a mixed market. The second question, Minister, is Shona Robison pledged to end delay discharge in 2015? The question is why, after such a long time, has social care sector not been given the resources to end bed blocking in the NHS? It is a complex, tricky challenge to fix. If it were easily fixable, we would have certainly done it by now. There is lots of work going on across the system all last winter. As soon as the winter was over, reflection began on how to rise and face the challenges that we would expect to meet this winter again. The situation that Scotland is in is not unique, so that is pretty similar all over the UK and it is pretty similar in many developed countries. There are a number of challenges. We were undoubtedly, as your question alludes, not rising to the challenge of delayed discharge prior to the pandemic, but we are in a really difficult situation now because of the pandemic. We have sustained pressure over the whole of our health and social care system for a number of years now. That is one of the reasons why we are in such a difficult situation with delayed discharges. We have, of course, got a whole new condition that is being coped with. There will be several hundred people in hospital today with Covid and Covid-related complications, so there is a whole extra condition to be coped with, as well as the fact that the staff and the systems have been experiencing sustained pressure for the past three years during the course of the pandemic. What are we going to do to improve it? We have a lot of work going on across the system, a lot of collaboration with local governance systems. We are producing dashboards of data, so we have spent some time over the course of the past few months improving the data that we can provide to ministers and local governance structures to ensure that there is quick action taken where problems are brewing. There is a suite of things that we know works, such as discharge before 12. There are programmes in place such as Home First, which is a really interesting programme. The early results are really impressive, so we probably need to, at pace, ensure that that programme increases and is delivered at a high level across the country. That is a programme that, instead of waiting for an assessment in a hospital if you are an inpatient in a hospital, instead of waiting for an assessment in a hospital environment, is discharged to home and assessed at home. What they are finding is clearly that a smaller package is required to support people at home if they are discharged quickly with support immediately. Obviously, that is something that we are striving to get spread all over the country. There is lots of work to be done, but there is no magic pill. If there was, we would do it, and everyone else in the UK would be doing it, too. Thank you. So, it sounds like you are doing a lot of work on delayed discharge? Yes. Thank you. Thank you. I want to move to Sandesh Gulhane, who joins us remotely. Thank you. I want to declare my interests as a practicing NHS GP. Minister, since the decision from the Scottish Government to go back out to consultation, what has been the cost to the taxpayer for the NCS Bill to tread water? I would challenge that narrative. We are not trading water. This is the second time I have been in front of this committee to explain exactly the level of work that is going on across the country. We paused and have worked very hard with partners, local government and trade unions and with people with lived experience to try to find a way forward. You will be aware that we were pretty much in a situation where we could not move forward because the level of opposition to the bill was so great, so I am really pleased that we have achieved consensus and we are now moving forward. I think that we provided the finance committee with costs for the bill so far last week, so I guess that if you check the papers from the finance committee from last week, you will be able to see set out exactly how much spending there has been on the bill at each stage of the way so far. So, what is that number, Minister? Sorry, could you say that again? What is that number? So, I do not have the numbers in front of me at the moment, but it is significantly less than was predicted because the paces of delivery is slower, so the slowing of the pace, the pausing and the phasing of the introduction of the national care service means that it is costing less. I do not know if you have the table in front of you, Donna. I do not have the table in front of me and I think that we probably also need to make the distinction between work that would have been under way anyway, so we always plan to do the work on the summer of co-design. The bill has been, or certainly stage one, will now take place before 31 January. It is quite a difficult judgment to make in terms of whether there has been a cost to delay or whether there has not, because the work that we had planned has just been rescheduled. As Ms Todd says, we provided information on the costs to develop the bill and the programme of activity. The bill is actually one part of the work. There are various engagement activities that are under way. There are also policy development and broader activities that are under way, too. We can certainly provide to the committee the information that we provided to the Finance Committee on spend to date on the bill, if that would be helpful. Let me get this straight. The Government created a bill and you said to me, Minister, that the significant opposition to the bill that the Conservatives brought up and discussed many times and the Government said they were just going to press ahead. It is now because of that opposition to the bill that you stopped to reconsider, but you do not think that that is treading water and you do not have figures to tell me what the cost was. If I say it was £15.4 million, would that be accurate? I am really sorry, I did not hear that figure. Could you repeat that figure, please? £15.4 million. No, we do not recognise that figure. I did not say that the Conservatives slowed the delivery of the bill. The Conservatives were one group that were opposed to the bill as introduced, but there was significant opposition to the bill as introduced. I think that it is reasonable in the face of significant opposition that the Government takes a pause and works with the people who are concerned about the direction of travel on the direction of travel, and that is what we have done. The bill will be delivered when we will finish stage one by the end of January next year. Of course, it is down to Parliament how fast it progresses through Parliament, but I would expect there to be significant progress in the next few months. Just to go back to what I would recommend people do is look at the Government's website, because there is so much comprehensive information about the national care service, all the reports, all the engagements over summer, and the work that is being done to connect locally. I think that it is great that Strunrair was one of the places, because I hope that Strunrair will always feel forgotten. How would the Government get the message out for people to look at what is on the Government website to show the power of work that is being done over the summer? What is the best way to share that information? A good question. There is a lot of work and a lot of evidence there. Perhaps there is almost too much and people are finding it hard to navigate the volume of information that is out there. We can certainly reflect on how to communicate. We have specific forums where we meet and hear from and talk to people with lived experience. We also have on-going engagement with trade unions, which has been vital to improve communication. When I first came into post, there were a number of people concerned about things that were not correct. Correcting those myths has been an important part of the work done during the course of the pause. We have a social media programme, which is a really rich bringing to life. It can be tough for what we all love reading. We read a lot for our work, but it can be tough for Joe Bloggs out there to read through pages and pages of information in somewhat dense text. There are voices of care videos that bring to life different aspects that we are working on, which I would definitely commend to people to have a look at. It really brings what we are trying to achieve to life. My question is not a criticism. It is just that there is comprehensive information out there. There are easy read documents for people. If you refer to videos as well, that is another great way for folk to watch videos on their phone or whatever. My point is that there is a lot of work that has been done over the summer. It would be good for people to be able to see that. Absolutely. We will certainly reflect more on how we can make sure that we highlight that to folk. You are absolutely right. There is a lot of detail out there. Just for clarity, Minister or your officials, the figures that Sandish Gullhane was asking for were made available to the Finance Committee, so those figures are published. Certainly, we can provide them to the committee if that would be a helpful thing to do. I think that that would be very helpful. Thank you. I am now going to move to Gillian Mackay. Thank you, convener, and good morning to the panel. With the pause on the national care service, some unpaid carers are concerned about the delay that that may mean to the right to breaks from caring coming into place. Could you update us, Minister, on what work is being done to progress this area while the bill is still being worked on? You are absolutely right. It is crucial that carers have a life alongside caring. I mentioned already that I meet so regularly with so many people involved in social care. People who are caring for members of their family are very often at the end of their tether. That is one of the reasons why I am absolutely passionate about getting caring shifted at a higher upstream towards early intervention and prevention so that people do not get to crisis point before help is available to them. It is absolutely crucial that carers have their own life alongside caring and that they are able to sustain their own health and wellbeing. We are doing a lot of work within the bill, as you are well aware, to enshrine that right to breaks. However, we are now acting to expand easy access to short breaks support ahead of the legislation, so we are not waiting for the legislation to make that change. We have increased the voluntary sector short breaks fund by £5 million to £8 million and we have maintained it at £8 million for £23 million to £24 million. That is in addition to the carers act funding, the £88.4 million that goes through the local government block grant. We are trying hard to support carers before making their right to a break before putting it on the face of the bill. The money is hugely welcome and I am sure that we would all welcome that. One of the other concerns that has been raised in particular with me is geographical variation. In those easy acts, as you are well aware, minister, being a rural constituency MSP, that geographic variation is also the variation in the support that is available. Not everyone wants what I am sure many of the general public would see traditional short breaks as many people want to be able to take their loved one with them on holiday and be supported in that way. In terms of geographic variation and the diversity of short break offering, what specific work is going on in those two areas to make sure that we are ahead of the game by the time the bill comes into force? That probably points to an issue and I keep saying that one size does not fit all. One of the things that we are trying to do with this legislation generally is to make it more person-centred, person-led, if I correct my own language as per our social covenant group guidance. We want it to be flexible and we want it to work for the people who are needing that support. We are going to need to work really hard on the ground to ensure that there is a person-led approach to this carer support. One of the things that I have been asked about before is things such as defining sufficient breaks. We could toil and come to an agreement on what the definition of that is, but more importantly it is whether the person who is accessing that support feels that they have had sufficient breaks. As in all things, we need to build something that is flexible, that is person-centred, person-led and that delivers the difference that we are hoping to see. That will be tough, as you say at the moment. We have a variety of options across the country, some easier to access than others, some more enticing than others. We are already working pretty hard across the board to try to improve that situation. I do not know whether you want to say anything. Build upon what the minister said is that, as part of our co-design but also with our stakeholder engagement, we are working with a stakeholder working group on this very issue to have them help us to define what those sufficient breaks would look like and mean to them. I know that those groups include representatives from islands and rural communities, so that is a very live issue that we have been discussing with them. It is really important that they have their voices heard to help us to work that through. I was just in a conversation last week about the reality of what a sufficient break means to a carer. That is where the voice of those unpaid carers in the room is really important. Local carers centres understand their communities and their community needs, so we are very committed to working with them to help us to develop those regulations and guidance to make sure that we truly are delivering it as consistently as possible across the country. I am going to move to Tess White, who has a follow-up follow-up. Minister, you recently told social care providers in Shetland that it is not our intention to come up here and tell you how to do things. How will the independence of local providers be respected when you are centralising social care across Scotland? I would challenge that narrative. We are not centralising social care across Scotland. I was very clear when I went to Shetland. We were really impressed by the level of integration that they were achieving and the work that was going on between the NHS and the local authority to ensure that there was a cohesive package of social care available to everyone. I joked with them maybe what we will do is pick up the Shetland way and roll that out over Scotland rather than us coming and imposing the Edinburgh way on Shetland. We will take the Shetland way all over Scotland. I think so that even in that room at that time we could recognise things that were so Shetland were doing excellently, but there were things that they needed national support with, and that is where we want to make the difference. For example, in terms of information sharing, that requires a bit of primary legislation in order to make that easier. Again, when you engage with people who live to experience, they are tired of telling their story again and again to everyone that they meet within the system. That ability to share information safely and appropriately within the system needs to be unlocked centrally by central government and we can do that and that will enable better local delivery. One of the things that we talked about was the challenge of recruiting social workers and professionals in Shetland. There are definitely things that we can do to support them with that nationally to make it easier to recruit, to make it easier to train, to take away some of the barriers to entry to training that there are in places like Shetland. Again, I am keen to hear what the challenges are in every local area and see what we can do nationally to unlock them. I am not interested in micromanaging the entirety of social care from Edinburgh all over the country. I have said time and time again that I live in the rural West Highlands. Social care in Ulipole, where I live, looks very different to social care in Inverness. Both of those are within NHS Highland. Even within local authorities, if they are to be responsive to the needs of their community, the geography and the situations that they face in terms of labour shortages, they will have to be flexible in how they deliver it. We are keen to create a system that supports and empowers that, while maintaining national standards, so that there is a clear expectation that wherever you are in the country, this is the standard, this is the quality that you can expect to access, but it might look a little bit different depending on where you access it. I thank the minister for social care and mental wellbeing in sport for attending today and to her officials for the information that they have provided and we are briefly going to suspend while we change panels. The third item on our agenda is a further session as part of the committee's pre-budget scrutiny for 2024-25. For this morning's session, I welcome to the meeting Richard McAllum, director of health finance and governance, Stephen Lee Ross, deputy director of health workforce planning and development, and Neave O'Connor, deputy director of director of population health, Scottish Government. We are going to move straight to questions and I am going first to Evelyn Tweet. Thank you, convener. My questions are probably for you, Richard, but if anyone else wants to come in, please do. Richard, are financial pressures evenly spread? My areas that are geographically remote or more deprived experience these issues more acutely. If so, how can this be mitigated against? I think the first thing to say and thanks, convener, for the invitation to speak this morning and I think we appreciate the chance to come along and actually the evidence that we've heard and some of the submissions that have come in from other areas have been really useful in helping inform our own budget considerations as we work forward and I know we'll get the report from the committee as well in due course, so that's much appreciated and I know actually on some of your specific points, Ms Tweet, in terms of the rurality factors that impact on the cost of services that has something that's come through in some of the evidence sessions from the likes of NHS borders and others as well. I mean, I think probably three things I would want to highlight. I mean, I think there are a number of, we know that there are financial pressures across the whole system and whether you're in a very urban or rural health board area or indeed in a more remote or rural area, some of those things are being felt across the system. We know we're seeing increases in inflation and that will affect all boards, so I think just to note that particular point. I mean, I think secondly though you are right and I think there are particular challenges that there can be for remote and rural boards in particular. We know that there's been some challenges particularly around recruitment and retention and that can drive additional costs as well. I think the third thing I'd say is well what are we doing about it and you know a couple of specific points on that. One, I mean we've talked before at this committee about the NRAC formula and actually that is the key and main driver of funding for health boards in Scotland and one of the factors that the NRAC formula takes into account is as well as age, deprivation and a number of other factors is remote and rural and it will take into account some of the factors that might drive increased costs. So when we're allocating to health boards we're actively taking account of the NRAC formula but I would also say as well we are trying to do specific actions as well as that specific investment on top of that as well so in primary care for example we're doing the remote and rural health care work at the moment through NES and three million is going to be invested over the course of the next year to support that work and that will help promote and support retention of services in remote and rural areas. Thanks for that answer. How are the short term needs and the long term needs being balanced? We heard a lot about both in evidence but especially in terms of preventative spend. Well maybe bring in Neven just a second in terms of some specific examples and I think I think the answer is we have to do both and the two aren't separate either so we know that we have some very acute and specific needs at the moment in terms of the backlog of people waiting for services and it's absolutely right and important that as we come into those budget considerations appropriate investment is given to support our health boards as they tackle those backlogs but equally we know that actually the longer term as you say realities is we need to actually get upstream and make sure that we're actually closing off at the source some of the pressures that we're seeing in our acute hospitals at the moment so whether that's in relation to the work that's been done in relation to multidisciplinary teams in a number of boards we've seen a big increase in that looking to actually drive more support and care for people in the community and indeed there's a whole lot more we do in terms of the wider investment whether it's minimum unit pricing or things in the alcohol space which are actually trying to support that very early prevention but I'll maybe bring in Neven to give some more specifics in terms of actions. Thank you Richard and the committee member is absolutely right I know in some of the written submissions that the committee has received there's been from Public Health Scotland or from Health and Social Care Partnerships has been referenced and from IPPR and there was evidence at the last committee session on this evidence around the Scottish burden of disease and if we just look at demographics alone then looking ahead to 2043 that forecast 21% increase in the disease burden I think the important thing to note from from that work is that that's without any impact of prevention or any impact of innovation so that's just looking at demographics and it means that and often they go together that prevention and innovation that without that sort of really embedded at the heart of the long-term reform efforts both population health and health and care system reform efforts we would really struggle to make the progress that we need to make so one of the the kind of vehicles that the care and wellbeing approaches as Audit Scotland mentioned in their submission spoke really about being clear about what we mean about prevention and preventative spend it's an often used word and can mean different things in different parts of the system so we worked with Public Health Scotland about 12 months ago now and in January there was a publication there on really clarity on what we mean by the public health approach to prevention and the role of NHS Scotland in that instance but there's obviously much much wider role for other budgets too and that really clarifies three big components of what we mean by prevention so primary prevention stopping those health problems from arising in the very first place so secondary prevent vaccination a classic example of that and the budgets around that key secondary prevention that finding health problems early and intervening to stop them worsening better outcomes for people screening a good example there and then tertiary prevention really managing established health problems as well as possible ideally close to home in order to minimise harms and that that clarity of that definition system wide whole system wide has been really important and we've been you know working then so we have that national clarity and national cross government work on some of those wider determinants of health those big building blocks and I know the committee will be fully aware that it's the the budgets outside the health and social care budget and the pre-budget scrutiny that you'll also be very much alert to in terms of their impact on poverty on housing on the things that we know drive health outcomes but there's also local examples of that prevention and action and that primary space so a lot of work around NHS Scotland really becoming proper anchor institutions with their huge footprint their ability to employ large people locally and use of land and assets so there's examples around anchors and also around service design and service change that's happening in in that tertiary space so shifting the balance of care very happy to give specific example of that if members would like to hear that community glaucoma this year is one so happy to say a little about that thank you very much sandish gohani thank you Richard you just spoke about the minimum unit pricing can you tell me exactly what benefit we've seen with that please yeah so um obviously that's work that's still ongoing and there's further discussion about that in in the coming months ahead but Public Health Scotland published a report at the end of June and it highlighted that minimum unit pricing as it is in its current form had reduced alcohol sales by 3% the death scores directly by alcohol had reduced by 13.4% and that hospital admissions had decreased by 4.1% so um you know this is something that that work and studies are ongoing but Public Health Scotland have put those you know they can't be specific but the estimates that they've put in suggest that that's an impact and a direct impact of the minimum unit pricing that we've had in place thank you for that because um bit confused uh because what you've just quoted for hospitalizations is not a significant figure so what what you just quoted there is an insignificant uh number so that's that can't be right um you talked about the death reduction that's not an accurate figure either is it because it's actually uh it's a potential reduction in an increase in rate versus england and dependent drinkers have been shown to continue to be drinking so could you just explain to me um how we've got how you have got that and said that on the record okay well i'll maybe ring in the volcano who's uh worked closely with Public Health Scotland who've produced the report that um that i was quoting from so i'll bring in Neva at this point thank you Richard and and thank you very much Dr Gilhane and uh the the um evaluation that that Richard just mentioned and i know you've um had concerns about that um in the public domain already so aware of that um i think the the key thing around that is like all um studies based on uh a robust evidence based our surveys or thing you know we can think about things like GDP or inflation figures the key thing there is is that they are estimates but that there is a real transparency of the robustness around which those estimates have been um derived so the the Public Health Scotland evaluation of MOP had a really robust governance process around the evaluation the details for that are in the public domain and the there is um you know expert opinion from people like Professor Sir Michael Marmot Professor Peter Rice who who've written a letter in in the Lancet that was published recently really expressing confidence in the robustness of the approach the robustness of the methodology but i know the Member has made very important points about clarity of communication around when things are estimates from studies and making sure that those are transferred into all products that try and explain the um results of in-depth evaluations and they're very valid points around use of for example the word estimate so that it's clear um in products like uh very brief evaluation findings or news releases for example that that that kind of nuance carries through into products like that and that's a very important point i think probably the the point going back to things like for example the UK stats authority is their fundamental point about the the findings in that final phs report have been communicated clearly and impartially and and i think there is confidence in the robustness of that evaluation thank you going to move to Emma Harper for a supplementary thank you convener it's just a quick supplementary minimum unit pricing was introduced we've also had a pandemic and we've heard that during the pandemic during lockdown that there was changes in the people's consumption of alcohol so some folk that drank a lot drank even more and some folk that drank less even drank less so what would be your thoughts on how the pandemic has affected alcohol consumption and has that skewed any of the minimum unit pricing information that has been brought forward happy to come in on that if that's okay richard so um certainly uh as the you know impact of the pandemic is understood more by global experts on alcohol consumption globally there's a growing consensus that it it did impact on population level drinking behaviours especially amongst the harmful and hazardous category of drinkers where there was increased consumption and we see really noticeable double digit increases in alcohol mortality in places like the us in canada and in other parts of the uk and there's a kind of growing global consensus that that is related to the pandemic so the the importance of the evaluation that we've just spoken about is those findings around deaths averted are kind of in a done in a control case around what would have happened if more hadn't been in place and so the findings of the evaluation were given that global pattern of impact of the pandemic on population level drinking behaviours without minimum unit pricing it's plausible that this mortality would have been much worse in scotland i'm aware too and if the if the committee member is comfortable i didn't pick up the previous committee member's point on dependent drinkers which is an important one i don't know if the committee member was happy if i cover that briefly now yeah i am so the the the very important point on dependent drinkers is that's a kind of small subset estimates vary but potentially around one percent of of the population who are that kind of extreme end of harmful and hazardous drinkers with clinical addiction needs that need clinical support and so and i know a number of members of the committee were part of the cross party work with the ncd alliance on that recently published report but there's a critical point there about packages of measures always being necessary for complex social outcomes there's never a silver bullet in any one of these and that's exactly the case for alcohol harm so prevention is in that primary secondary tertiary it's a it's a kind of spectrum and so there's a range of measures around alcohol pre-interventions, UK clinical guidance getting updated, the investment going through ADPs to really support improvements in treatment for those suffering from alcohol dependency and addiction but it's a very important point that the committee makes well and we now have a minister that has a combined portfolio of drugs and alcohol and again minimum unit pricing isn't the only action that is being taken forward as a public health approach and you mentioned the non-communicable disease alliance which i was part of that report that was created by them regarding our ncd's thank you i'm now going to move to tis wait thank you combina um this is a nuts and bolts question first so mr mcallum how how is the allocation of social care agreed within the overall health and social care budget thank you yeah so i mean this is something that um you know we have conversations not just within health but within local government and with with conversations with coxler and and that's as part of the the discussion that we'll be having in the coming weeks and months as we move up to to the budget period um so we this is something that we would take forward in conjunction with wider Scottish government colleagues but as i say with with external stakeholders particularly coxler as well i mean i think the key thing that we've that we'll be particularly considering is is the commitments that have been made and shaped around both the policy prospectus and indeed the programme for government so as you'll be aware one of the key commitments is around the increase in adult commission services for social care to 12 pounds an hour and that will be one consideration that we will be taking into into account and being considered the other fact i think that that we will be playing through and we'll be considering as part of the budget process is that overall allocation to health boards and health boards do allocate on a further element to integration authorities as well and integration authorities have that overall budget responsibility across a range of health and social care services and so some of the consideration will be in that space as well of of the allocation of funds to ultimately to ijbs okay so different stakeholders pulling in the the data so um a second question relates to there was a we had a previous committee session where phyllic white of the institute for public policy research said when it comes to staff funding resources and everything else the balance of where we deliver care is still very much stuck in the secondary first model rather than starting to look at what we can do to bolster the role of primary care so the question is is this a fair assessment in your opinion and has primary care been given the funding it needs so i think this is a a point that has been considered and and again probably has been considered by this committee i think for some time and we've talked about that shift in the balance of spend from sort of secondary acute care over to community primary care and a commitment from from Scottish government ministers to see that shift beyond 50 percent over the lifetime of this parliament we're actually at a point where where we're just short of that we're about 49.2 percent i think in that position and i think one of the key considerations part of this budget and in budgets in future years will be in relation to to to make in that shift happen so a very sort of strategic level um i would say that there's that kind of that there's that key focus if you like of moving spend i think in relation to to to primary care um so again key commitment from from ministers around that increase in primary care funding so if i take something like the primary care improvement fund as an example we've seen that grow from 155 million a couple of years ago to 170 million a year ago to 190 million in the current financial year and i guess again one of the key considerations for us because i think it is a fair challenge back and a fair challenge about primary care is is to see that increase further and we know that there's really good evidence already coming through for the work we're doing in relation to multidisciplinary teams to community link workers that's having a real impact and that's something that certainly is part of the the budget consideration and indeed i think some of the the evidence that you've you've already received that will be a big part of our considerations i'm not sure if either of my colleagues want to come in and say any more on that point i'm happy to come in with a very specific example if the member would find that useful so sometimes we can talk about shifting the balance of care in quite an abstract way but i mentioned the community glaucoma service in that example of tertiary prevention so managing a condition as well as possible ideally close to home and that's a service that after you know a good number of years work with community optometry with the ophthalmology profession with patients receiving the service has now been rolled out NHS Greater Glasgow and Clyde for sending letters out to patients and the service discharges for clinically appropriate patients with glaucoma to management in the community so from the hospitalised service and this care closer to home it's a kind of concrete example of shifting that balance of care with appropriate work happening with our national boards including nez on the kind of workforce developments required for that and at its full rollout that service should be able to see up to 20 000 patients NHS Lanarkshire is next in November in terms of rollout and we know ophthalmology is often one of the top busiest outpatient specialties so we can see specific examples of that shifting the balance of care happening that that philip white that you mentioned referred to in his advice in his evidence it all sounds really good but the question is in terms of last year the Scottish Government cuts £65 million from the primary care budget that's £65 million is a huge amount of money so how is primary care meant to cope with increasing demands when services are being cut like this yeah so so a couple of things on that and I think you're referring to the the emergency budget revision that that happened in in November last year so specifically that that that budget decision was taken in the context of a very you know challenging financial settlement generally across the Scottish Government and actually all portfolios were looking at the financial challenge that that that was that was faced I think what I would say is that that was a non-recurring reduction so you know it's not that that is continued indefinitely so whilst there was that that pressure was recognised as part of the the 22 23 financial position that isn't 65 million that has that has gone recurringly from from primary care I think it was recognising as well that as as as we've built up additional funding in primary care over a number of years actually that some of the money that's been allocated I mentioned IJBs is is in IJB reserves and so rather than allocating additional funding to support things like the primary care improvement fund there was an expectation that the integration authorities would use their reserves in the first instance before that additional funding was allocated so that was the that was the decision around that that 65 million as I say that's not something that's rolled forward into the current financial year and we know as you say that primary care is is incredibly important as as we move forward and so that'll be something as I say that we'll consider as part of the the 24-25 budget as well thank you thank you I'm fine thank you thank you thank you I'm now going to move to Jillian Mackay many submissions to the committee highlighted the difficulty of engaging in forward planning and prevention while relying on single-year funding settlements which may be linked to evidence of performance in the short term can the panel advise how the government is working with health boards to support them to engage in long-term financial planning and how likely is it that we can move to a system of multi-year budgeting in your opinion given that many of the scottish government's budgetary decisions are reliant on those of the UK government yeah so and I think it's a fair challenge and I know that a number of boards and others have raised this with with the committee so I think there's two fundamental points in in relation to this and I think miss mckay you've picked up on one of them and that is that um we are in a in a cycle of of largely single-year budgets as a government you know we as you say that ultimately um money is is allocated on that barnet basis from the UK government and actually planning ahead when there's uncertainty beyond the current year is quite it's quite difficult now that's not to say we don't work closely with the treasury um and the Department of Health and Social Care at a UK government level to understand expectations and plans but in a formal sense you know even the budget this year will will come after the autumn statement in in in in Westminster so we are working in that that environment and actually I suppose even over the last couple of years with some of the general uncertainties we've seen around COVID money pay and other things actually that that planning is quite difficult but we do so so I think there's that challenge but the second thing I would say is um yes there is you know multi-year budgeting would would absolutely help but what we have tried to do and we work very closely with health boards and integration authorities on this is to to give them some planning assumptions for for future years so if I take something like the the drugs budget that we've mentioned already there's a commitment for a 250 million pound investment over the lifetime of that parliament so boards should be going away i jb's other partners and working on that basis you know there's there's there's not any expectation that we will stray from that if anything um you know we would consider putting more investment in into the into that and I think we've done that across a number of areas mental health primary care we've already mentioned as well as some of the planned care investment so yes it's it there is that challenge but we're trying to give within that context health boards integration authorities as many planning parameters as as as is possible that's great thank you and date has a particular bugbear of of mine and particularly how that informs budgets and and outcomes as well so how can data collection be improved to ensure it's not only sufficient to measure performance but it's also linked to long-term outcomes and therefore informing budgets and and other things going forward yeah so so nif might want to come in and in some of the specifics so I would I would hope that actually at a strategic level there is evidence and information that's supporting all our budget decisions so even if I take something as specific as some of the planned care investment that has been made over the last couple of years and as that's considered as part of of of this budget I think we will want to be absolutely clear what what we expect boards to deliver and what improvements in line with the trajectories that the cabinet secretary set out in the programme for government and in the mandate letter we want to be absolutely clear on those on those outputs and maybe there are more outputs and outcomes but we would want to be absolutely clear on that equally I mean nif mentions the example of the multidisciplinary teams we're starting to build up some really strong evidence about the difference that those teams are making across primary care mental health and in other areas as well so as we are working through this and again it's something that we'll be doing in conjunction with stakeholders you're absolutely right absolutely key that we we draw on that data and we're making sure that our budget investment decisions are based on where we're seeing that real impact and change but nif you work closely with public health Scotland so I don't if you want to say more in terms of their input in some of us happy to briefly if the committee members content because I know the committee have had a concern around the multiplicity of outcomes frameworks or other ways of understanding change I guess the important thing there is is understanding which data to go to for what purpose so for some things where we're needing to track investment or needing to track activity so inputs into the system there will be things like previous ldp standards and that kind of activity really and I think the committee member was asking about outcomes how do we know we're making a difference on the outcomes we're seeking and public health Scotland are our public body who are our experts on prevention and there are experts on data and analysis and there's work happening there not trying to duplicate things like the national performance framework but being really clear around what we know drives health and health inequalities what the measures are around those around early years good work good income our outcome indicators around all that and and learning on the experience from Covid so producing dashboards working with the improvement service and so that they're useful locally in community planning when people are organising efforts to address health inequalities and health outcomes locally and that care and well being dashboard it's called was was launched in June and that's really how we track progress on those overall outcomes and evaluation again then is the key link between the data on our interventions and our activities the data on the outcomes and then what's plausibly driving those both the things within the the gift of the Scottish Government as a whole and obviously wider factors of which there has been a number in the last decade I'm now going to move to carol malkin being there thanks thank you very much I think that this question probably just links in to what you've just been saying but I'm interested to know if and how the Scottish Government tracks spending by NHS board on what are their current Scottish Government policy priorities yeah so I'll bring neave maybe in a second on a couple of the specifics but in a general sense we we obviously work through our policy teams within government and whether it's in relation to specific commitments on mental health or alcohol or drugs we work very closely with our boards and ijbs to to get information and and have that information return to us for this clarity on not just the spend but as you say crucially what what what investment is being made on that spend and what early outcomes are starting to be to be seen at a data level and again this speaks to work that Public Health Scotland do we we on an annual basis have a cost book which shows which translates essentially the the budget and what has been invested by the Scottish Government and looks and tracks across to how that has then been spent by by our health boards and that starts to give a good picture although there's a there's a lag in time there's a few months after the the year end that we get that information that gives us a good sense that the areas where we're focused on investing which we've mentioned and looking to see more investment in the community is that being borne out in reality and the past two two to three years have been difficult and they've skewed that probably somewhat because of the the challenge of the pandemic but we're building that that evidence and data back up in terms of that that overall cost book data and that's something that we'll certainly be looking to to build on as we move forward but I'm not sure if there's anything you want to add me I can briefly add so so Richard's spoken about tracking investment and and I know the member was also asking about outcomes by board against things like the prospectus and the commitments in there so that dashboard that I mentioned that Public Health Scotland have launched now that all the data in there on the evidence that we know influences health and health outcomes is available by health board area it can be broken down it's at an early stage now so information is getting added to that and there's work happening if it's available by local authority area work happening to make that breakdown available so that's that's one part of the the kind of tracking outcomes by geography and the second part is is just I suppose to amplify Richard's point about investment is clearly critical in prevention not least investment with the health and social care budget so so those very big investments and things like the Scottish child payment but when we look back maybe over the last 20 years and in some of the things that have made the biggest difference in public health and in preventing ill health and in improvements in mortality for example in cardiovascular disease really the role of legislation has been very important there too so some of those non-fiscal interventions things like the smoking ban in 2006 and that kind of package of things over time and I know that was in the written submission from phs to so yeah so I hope that's helpful yeah helpful I suppose just to come back a little bit about so sometimes particularly in big spends and then you're trying to see where money's moved about do you think there could be more or do you think we could record anything differently or in a better way to ensure scrutiny and transparency of where some of the money actually goes once it's in the system yeah I mean I think you know in some ways if we take the budget as an example and it's rightly so but we you as a committee will see that by often to the large spend areas whether that's in plan care or or other areas and then broken down by health board but you don't necessarily get then get that that detail and data of how it's subsequently spent I mean I mentioned the cost book I think that's really critical actually in terms of the translation through and is the budget that we've set is that coming through and is that being shown in the spend that's that's ultimately being taken forward by health boards and others but it's something that I think you know we will want to do and we are doing more on as we as we move forward with some of these key investment areas that we've talked about and actually it's something that we'd welcome coming back to the committee on and giving you that data because I think that it's it's really important and helpful for for you obviously to see that as as well yeah just to close off I think you know there have been advances in mental health service budgets and we can see more clearly and just on what you're saying there the scope to look at other areas I think would be very helpful for for members and for the committee as a whole thank you very much thank you carol yeah i'm going to go go go go go thank you convener I suppose my question is very similar to carols because I would just like to know if you feel that we have enough transparency in the way that money is spent taxpayers money is spent and our ability to really track it so that we know where all that money is going yeah so I so I hope that that so there's no secret in terms of that that the the investment that we put in into to the health and social care system and I would I would hope if there's information that you as a committee feel you're not seeing or you would like more on then I would be really pleased to actually give you that because I think you know it's absolutely critical that you can see that and you are able to to hold us to account on those on those things I mean I think in in answer to the question yes I do think we've got good information in terms of of the cost data that we have but we can always improve it as well and and I think there's there's so I would see it at two levels in in particular dr Gilhane so I think at a health board an ijb level is absolutely important that for local communities they've got a clear sense of of where boards and integration authorities are investing their spend now we do get annual reports by both integration authorities and health boards which set out that and I think that does give that that detail on at least on an annual basis which gives a sense of of how that money that has been allocated to to those areas has been taken forward and I think that's absolutely critically important similarly at a national level we are pulling through through I've mentioned the Cospic already in terms of that data in terms of overall spend but we have also as a government we've asked on specific areas integration authorities in particular to detail how they've used particular funding streams mental health is one that miss Mocken mentioned but there are other areas as well where we where we've got that that information and we are pulling through that data but if we can do more to to give the committee that that information or indeed make that public then be very happy to do that because I think it's absolutely important that we're transparent in in that tracking of spend thank you it's just in in previous sessions that we've had we've been told that it's very difficult to track whether money has been spent and how the money is being spent and where it's going so so that that's why I asked my question because I think it's very important that we are able to transparently and very clearly define where taxpayers money is going so so just from your answer do you feel that you can track all the money that's being spent and and exactly where it's going so I mean it's a it's it's a huge budget obviously and and and and there is investment made in in many different areas and and many different kind of priorities across health and and social care but I mean as I say I think at a local level health boards and ijbs can certainly provide a lot of that data and a lot of that information and as I say indeed they already are in in the annual reports that that they produce and we we follow up and we track in in terms of all investment and going back to miss mckay's earlier question I mean one of the absolutely key things particularly in the financial constraints that that that that we will have and we'll see likely over the next few years is we need to be confident that the investment we are making is actually having the differences that we want to see happen so um you know I there can be challenges there can be challenges getting that information back in a timely way we want to make sure the information is accurate going back to your to your earlier question but I think there is a there is a clear way that we will and we can track through that spend and certainly on some of the specific policy areas that we have already picked up on or touched on today then yes absolutely and and as I say I'd be more than happy to to provide as much of that to the committee as as you would find helpful thank you and just to declare my interest in practicing interest GP in the now thank you and I'll move to Stephanie Callan thank you convener and and certainly many many of the questions that I had today have already been answered in in touched upon there um I suppose you know we've heard about the wellbeing dashboard and we do hear a lot that short term targets can drive the decision making so really interested in those longer term objectives and what can we be doing to to encourage that budgets are really set with this in mind yeah so I'll I mean leave my one to say a little bit more maybe about even the care and wellbeing portfolio and the work that's being taken forward there but I think just just as a sort of starting point and again going back to to the programme for government and and the mandate letter that that that was issued about a month or so ago I mean that that will be the primary consideration and primary driver as we as we take forward our our budget considerations and I think the the cabinet secretary has has been absolutely clear that it's about recovery and reform and and holding those two things together and we know that there are certain immediate pressures on in-secondary care and there are immediate pressures in both plan than unscheduled care where if there is additional investment that can be made and made in an effective way then then we should look at the options of taking that forward and indeed some of the some of the investment that we've seen around things like hospital at home has been absolutely to support that but I think that the point is I wouldn't just see that as a short-term investment so hospital at home if I give that as an example yes we hope that that will have an impact this winter and help the unscheduled care and challenges that will undoubtedly face this winter but this is a this is a long-term solution as well actually and the outcomes for care and treatment at home are good and better for those that receive that so I do think there is there is a balance to be struck by recognising yes there is that short-term investment but we do see that playing out with a you know a longer term in in mind as well but I think that reform element is is absolutely key and we're using the care and wellbeing portfolio which I think the committee has received evidence on before I think was maybe discussed at the pfg session with a cabsec on and I think that will be a really key mechanism for driving forward some of the reform which you mentioned but I don't know neither if there's anything specific that you'd want to pick up on beyond what we've already said touch on you know actually keeping people's experiences at the centre at the centre of that as well thanks so yes absolutely there's the the the portfolio the the point of it is to be the long-term reform place around both population health so those big risk behaviours that we've spoken about already in the context that reduce them and service reform and also whole system including sort of wider government so that three billion investment in attack in tackling poverty for example absolutely critical around benefits and those building blocks of health but that long term the the point of the portfolio is to try and bring those reforms all into one place and so there's work on and besides the service reform we've spoken about or the population health we've spoken about those measures work on things like innovation digital you know analysis really building those capabilities I guess in Scotland so that we're we're best able to deal with long-term challenges one of those other big cross cutting areas is co-design service design and engagement and I know the committee may have already heard about some of the summer design events this morning around national care service development so part of that has been the establishment of a lived experience expert panel and we know that when we speak to people people don't live in policy siloed lives you know if we're speaking about our experiences of social care often that will extend to our experiences of healthcare services locally and that information is all being gathered together and used to inform that thinking around the long term reform and building that sort of building block around constant public engagement that we need in order to reform services for the long term thank you and I suppose that kind of leads me on to to my next question as well there and I'm wondering how can the interdependencies between different spending areas be better taken into account when when we can budget systems and we're looking at performance frameworks? I mean I'll take this in in the first instance I think so I think there's a couple of things I mean kneeves touched already on when we talk about some of the primary prevention actually a lot of that spend is is one outside of the health and social care portfolio so I think one of the really key things is that that as we as we move forward not just with this budget but but actually subsequent budgets as well is that there is that real clear connection across whether it's education, justice, housing, local government that it's that it is a whole system and it's a whole package and there's that consideration over a number of areas within within the portfolio as well though I think there is a lot that we are doing and no doubt there is more we could do so we know I mean we've talked about primary care and that being you know that place where most interactions help happen in our health and social care system or certainly in our health system and I think some of the the work that's been done around multi-disciplinary teams that we've touched on community link workers as well it's having a real impact on some of the the investment that we're having in relation to mental health and in relation to to some other conditions as well so we're starting to build up that that you know we're not seeing within our own portfolio that siloed approach but we're trying to make sure that our investment is coming together through the portfolio that needs mentioned so that we're not you know that we're making the best funding decisions and making sure that it reaches the people in the best way that it possibly can thanks I can add a specific example if the member would find that useful so we spoke a little about benefits there and about things like the Scottish child payment and the impact on the building block of addressing poverty now obviously that impact on preventing ill health is only felt if individuals claim or have access to the benefits that they're entitled to so there's a lot of work happening in the interdependencies between NHS services and wider services to ensure income maximisation NHS Lothian is a recent example for they've established income maximisation services now across every hospital in the NHS Lothian estate and they're starting to gather management information around that so in the nine months just up until June this year over 700 patients often at vulnerable points in their lives obviously accessing health care got the benefit of that income maximisation service a kind of whole systems funded partly by NHS Lothian charity managed by and overseen as well by the the kind of public health experts in NHS Lothian and some of that management information some of that kind of confirmed financial gain is around £400,000 just in that nine month period so so it's that combination of national interdependencies and then local action because as I said that the impact on on preventing ill health is only experienced where households have the benefit of those national policy changes in things like the Scottish child payment that's great a great example thanks very much Paul Sweeney thank you convener and thank you to the panel for their contributions so far just to turn to health and social care outcomes a lot of written submissions to the committee have noted that the short term nature of national targets is impacting clinical priorities for investment with decisions often made to satisfy expectations in the short term as opposed to measuring long term impact with patient investment do the panel have a view on alternative measures that could be used to monitor performance that allow for longer term planning and more rational decision making on investments as a result yeah I mean obviously this is a consideration for ministers in the in the in the first instance I think you know probably in terms of the investment decisions or the choices that we're making I don't see it as an either or in some ways in that we know that there are particular immediate or more immediate standards that that you know our reference for example in the the programme for government and improvements that we want to see and I think that's absolutely right and absolutely the expectation of of the population and certainly in terms of some of our investment decisions that's certainly where you know we we're making sure that that's that's absolutely factored in but I think you know there is you know a key need that we do have an eye to that longer term and that we aren't you know we're not just making those kind of short term just financial decisions that will will meet the meet the immediate pressures I mean I do think the the math standards that we've seen in in in relation to the national drugs mission I think is a really important one where you see this combination of yes we want to see improvement in the short term however there is a longer term need to address and a longer term challenge as well I think we can build up more and actually the work that Public Health Scotland are doing to to look at some of that data over a longer period will help to inform as the member said some of those longer term targets that we should have but I think it's that you know and certainly I think in terms of where we we are getting to in terms of the budget choices that we have it's finding that right balance between those those immediate service needs and that longer term focus as well thank you you got a further question mr Sweeney yeah sorry I was just waiting for the unmuting to happen sorry about that yeah I think that point is fairly made however I've recently met for example with GPs in Glasgow who've said they're so focused and overwhelmed really with dealing with the immediate clinical requirements that any headspace any time available to look at continuous improvement process improvement with their teams in practice is just not feasible there isn't the capacity or space to do that sort of activity and that really goes to the core of the tension between short term firefighting and longer term continuous improvement the biggest commodity in NHS is of course time so how do we try and move the organization as a learning organization if you like away from that kind of short term firefighting and crisis mode into creating that space for for continuous improvement for work streams that can help to drive that activity is there an account management service for example ours are specialisms you're bringing in from other industries I know a lot of economists say you know look to the aerospace industry for example for good examples on how to drive productivity obviously the NHS is the single biggest employer in Scotland it's going to have a national impact on performance how do we move to getting the everyday economy in areas like the NHS actually mobilizing the same way how do we bring that culture of productivity improvement into the NHS have you any ideas on how that can be achieved yeah no I think I think it's a really really fair challenge back and I think one of the one of the realities as as the whole committee will know is we are in a context where after two or three years where a lot of a lot of our services for understandable reasons were or scaled back or curtailed has meant that we do have a backlog that that does mean that there is a real challenge in the media and actually that investment is is is really important I mean I think specifically I'll bring Steven in a second in terms of some of the work that you know what we're doing with system leaders to try and look at that question about developing our staff leadership productivity all those points I think I think particularly on the the primary care point that that that you raised Mr Sweeney I think I think that's that is a challenge I think the investment that has been made around multidisciplinary teams you know where we have seen a growth of of over four and a half thousand MDTs now working in our system in Scotland I think that is going to have an impact it's something that we're looking at in future and and you know in terms of the pressure that there are on GPs as given the example you've you've highlighted you know that's something where we hope that that will have an impact and assist GPs as we move forward and clearly phase two of the contract is going to be a kind of key part of that and I know you've got evidence from primary care colleagues coming up where I'm sure they'd be happy to to expand on some of these points but I think your point about productivity is right in that there is partly something about the money that we invest but it's also making sure that we get the best value for the money that we invest as well and making sure that we are as productive a system that we can possibly be whilst recognising that our staff have obviously been through some some really significant challenges in many instances over the last couple of years so you know I think it's holding that balance in line I don't know Steve you want to talk about some of the work that we've done with with our staff to support as well yeah happy to I suppose to just pick up a a couple of broad strategic points and there may be a couple of particular examples just in terms of that that overarching question on productivity one of the things that we've tried to do through framing the new national health and social care workforce strategy which we published in March 2022 was draw out the relationship between recruitment staff development training and the infrastructure tech and tools in which the staff do their jobs and part of what we're now trying to embed through the workforce strategy implementation programme is drawing out some of the links in terms of that relationship particularly between where staff are working and how staff are working in terms of their relationship between one team and another and their access to tools and equipment so in addition I suppose just picking up the point that Richard was making in terms of trying to kind of encourage whole system recovery post-acute phase of the pandemic we've invested as set out in the strategy quite significantly I suppose both in physical and psychological support for staff both to not only to kind of encourage attendance but also to allow them to sort of reset and rebalance themselves post pandemic Richard's already picked up the point about the growth in staffing in MDTs and we can see through the national monitoring and evaluation strategy through some locality-based evidence where that is already having an impact in terms of releasing in relation to your question GP time through embedding sort of additional physical support community link worker support and also pharmacotherapy support and that's also demonstrating a more efficient use of resources with better patient outcomes particularly in relation to some of the pharmacotherapy examples we've also us through looking at I suppose our approach to planned care recovery staffing and productivity in partnership with the the centre for sustainable delivery looked at a range of interventions that try and increase the productive opportunity within those centres without as I have to stress that meaning that staff are working more hours or doing or doing more work it's about aligning I suppose the whole of that system end to end and looking at the productive capacity across across the whole of our estate within NHS Scotland so through the national elective coordination unit for instance we've managed to manage to utilise what was previously a little fellow capacity in certain theatres throughout the country delivering about I think it's about three and a half thousand so far over the course of this year additional elective procedures and we've also been looking at I suppose the structuring of teams and workforce diversification within that area in particular to try and progressively improve productivity without increasing the burden on the direct burden on staff in front line services. Thanks for that. Do you feel that it will certainly lean improvements continuous improvements driven by the ground up and it's often the innovators at the front line who can have the best insights on what we need to do to improve productivity and efficiency with that in mind do you feel that we could do more in terms of continuous professional development in terms of even looking across different agencies of the the Scottish Government such as Scottish Enterprise, the Scottish Manufacturing Advisory Service to perhaps teach more tools and techniques that could allow more practitioners within the national health service to sort of identify opportunities where there are waste and where opportunities for efficiency could be achieved and start to organically develop those ideas and moving forward. Yeah I mean I'll come in the first instance I don't know if Steve might want to add a couple of things but maybe just giving one example I think I think you're right in terms of you know often it's our our staff who have those good ideas and have those ideas in terms of how we can improve our work and I mean if I take a specific example about in relation to climate you know the national green theatre's work that we are taking forward has been clinician led you know clinicians for particularly in NHS Highland have come together and seen actually that there is you know not just efficiencies in terms of monetary or productive efficiencies but actually from a climate and sustainability perspective some of the work that's been done around anaesthetic gases some of the work around kind of waste separation that's all been led by you know it's not been an edict from from from on high albeit you know we're very focused in terms of the work that's going on in in relation to sustainability but but that was something that theatre's project that was absolutely led by teams in the system and I think you're right how we harness that is is going to be keep going forward because that's often where where the best innovative ideas come from that said you know we you know there is wider harnessing you mentioned Scottish Enterprise you know across certainly our innovation landscape we're doing a lot of work with with colleagues in in Scottish Enterprise and in the economy directorate within the Scottish Government around some of the the research projects that we have underway and we've seen some real benefit coming through in that in terms of some of the work around closed loop diabetes in relation to theatre scheduling and other things so there's quite a lot of innovative work that can be done we need to make sure that we invest that and people have the time to focus on that but I think that's something that that given the challenges we face is absolutely right we drive forward don't know if anything you'd want to add to the evil I suppose just a couple of other practical examples so we again through our work on on kind of elective recovery we we did a bit of a bottom-up approach in terms of developing staffing models directly with theatre teams across the national treatment centres that have opened or in the process opening over the course of this year particular with Highland and with Fife and with the Golden Jubilee where we were actually I suppose looking at and inviting staff themselves clinical staff to challenge assumptions around staffing the staffing model and the staffing mix and inviting them also I suppose to engage with some of those some of the challenges that there are in the in the wider kind of economy around attraction of particular groups of staff and looking at what alternative staffing solutions there might be that led to some positive change in terms of rethinking the mix in particular in particular in the centre in Inverness rebalancing the number of registrants who support staff and also begins to feed into something of a bit of a pipeline when you tie it together with the work that's being done around anchors and future development that being said there is obviously I think going to have to be an increased focus on on on I suppose the productive capacity and opportunity that might come through future technological innovation both in terms of how our staff work and the tools that they have to do their jobs and that again is something that we framed in outline within the national workforce strategy there's there's some further work to do in terms of scoping I suppose where we might be over the next five to 10 years in terms of AI there's quite a lot being done in the context of the innovation authority in terms of AI and imaging and how that supports imaging staff as well but it can also support with the administration of staffing potentially and and how they're rosted and used throughout the system so there's some systems innovation as well that that is I suppose being driven by the wider the wider landscape that we can look to embed as part of kind of managing that overall approach to balancing staffing productivity and service need going forward thanks very much computer thank you we have limited time left and we still have quite a few questions to ask so if I can ask contributors to be brief and with that I have to practice what I preach make a declaration that I'm registered mental health nurse and I'm keen to move on to workforce and pay and I'm keen to explore how the twin pressures of increased pay and demands for additional staff can be balanced in the nhs and social care within the limited resources of the Scottish Government budget and obviously it's limited borrowing powers so I don't know perhaps that's one for you Stephen yeah I'm happy to make a start I suppose at the outset we took a kind of a clear overall strategic approach in reaching the pay settlements we have this year both for agenda for change staff and for doctors and dentists about I suppose seeking to to make a fair proportionate and reasonable settlement in the context of the wider economic circumstances and also managing looking to proactively minimise the disruption that would have occurred if we if there'd been a breakdown in industrial relations I think there's two two points about the balance looking ahead if I can and I'll try and be brief as possible I think one is that you have to look at the the totality of terms and conditions so whilst we've we've made the investments that we have over the course of this year and obviously pay will continue to be determined you know going forward through that tripartite process directly with unions we are looking at the balance of investment in pay going forward with progressive terms and conditions reform because it's the total package when you look internationally at the benchmarks that makes careers in health and social care attractive and in the context I've suppose of present-day shortages in health and social care personnel retention is as important if not more important particularly as we have acute pressures that then I suppose thinking about when you compare it with investment in recruitment should I say that's not to say that you that you you know spend on one in in favour of the other but you have to I suppose take those strategic decisions in in the total kind of economic context in which we're operating okay thank you thank you for your brevity in that complex answer I'm now going to move to Emma Harper thanks convener I will be quick because a lot of information has been covered already and when we took took evidence in the last session they talked a lot about like whole systems approaches to the budget because we need to we know that you know we need to tackle poverty we need to look at health inequalities it impacts on housing it's it's it's loads of umbrellas that need to help support improving the health of the people in Scotland so I'm interested in the public health aspects of it and the preventative approaches and I'm interested in you know like better ability to have good healthy diets for instance I'm interested in the work of Henry Dimbolby and Chris Van Tullerkin and what Professor Pekka Puska did in Finland in order to improve the diet and reduce carovascular disease so so what work is being done to learn from other researchers that aren't even in Scotland to look at how we can I suppose budget better for public health measures sure I'll bring in Neave who will be able to give some of the specifics on that but but you're right I mean ultimately it all comes back to to evidence-based budgeting and I think that's what we are seeking to do on a on a kind of global scale but even on a kind of granular scale so we talk about diet and obesity and the investment that we're putting in there you know really key for for us when we're making those investment decisions when the policy teams are considering this is what is that international evidence showing us and what can we you know how can we evaluate that as effectively as possible so that that investment that we're making really maximises the the contribution that that we're putting in but Neave I don't know if you want to say anything more specific in short of time I'll be brief I mean it's it's exactly as members of the committee on the ncd alliance report said you know it's that whole package of measures in terms of learning from from other systems if we think about the criticality of early years heckman curve return on investment you know that's part of the nutrition policy landscape as well so the the flea vitamins to under threes or to breastfeeding mothers so that kind of whole system approach to the example used of of kind of diet and healthy weight has to start at the very very very earliest and then has to be that whole package of measures including legislative as well as fiscal and I know when minister for public health and women's health was here for the pfg session recently she was signposting that the next step on the promotions around and trying to restrict promotions around foods high in in fat sugars and salt which I know is has got a strong overlap with some of those dimbleby concerns you mentioned earlier and that's certainly you know very active work on bringing that forward as soon as possible and the institute for fiscal studies have a report out about future planning and short and medium term and long-term planning as well which is interesting and they focus on basically the Scottish government's budget for health depends on Barnett consequentials so it's determined by the UK government so does that pose challenges in planning if we don't know what is coming from the UK government for instance in order to determine what needs to be incorporated into whether it's preventative health planning or acute acute planning yeah I mean it sort of loops back to to miss McI's question earlier I mean it it it generally at the moment we are getting those those consequentials on a on an annual basis albeit we've got some some assumptions that we're making into into future years I mean I obviously once the total Scottish government budget comes ministers can choose to use that how how they wish but if we were to put even more into health that would be at the expense of other portfolios that have you know you know equally pressing needs and actually already as a as a government you know in the last year in excess of consequentials has been has been put towards the health and and social care budget so so it is a challenge and that's something that needs to be worked through but within that context we're trying to make sure that you know we have a clear financial framework as far as we can that we we use to make the decisions that will impact over the next five to ten years okay thank you and we're going to go over to Paul Sweeney for one final brief supplementary thank you convener just intrigued about the practical realities of how do you pivot the healthcare system from current acute spend in hospitals towards preventative spend within communities we know that we spend more on acute hospitals in any other healthcare system in the world how do we practically shift the balance yeah so I mean I think I mean it it does link to a lot of what we've said I think there will be a better it's partly about some of that upfront investment that that we've made and I think you know building on some of the investment that's been made in some of these preventative areas will need to continue I don't necessarily see the two as as an either or and I think that that you know there is you know something about important that we do continue to invest in our our our kind of secondary care services and make sure that that that funding is available and and as we need but you know I think I think it's going to be partly through some of those deliberate budget choices but not just budget choices some of the policy choices that don't necessarily come with huge financial costs as well that will start to help to to shift some of that that narrative and shift some of that service delivery thank you very much thank you can I thank the panel for the attendance this morning and for the evidence that they have given to committee at our next meeting on the 24th of October we plan to take further evidence on the national care service Scotland bill and that concludes the public part of our meeting today