Health, Social Care and Sport Committee [Draft]

Meeting date: Tuesday, June 4, 2024

Official Report 820KB pdf

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National Health Service Waiting Times

The second item is an evidence session on NHS waiting times. I welcome to the committee Katie Cuthbertson, who is the national director of NHS Scotland’s national centre for sustainable delivery; Professor Farhat Din, who is a council member of the Royal College of Surgeons of Edinburgh; and Peter Hastie, who is the policy and public affairs manger, Scotland, from Macmillan Cancer Support. Max Warner, who joins us remotely, is a research economist at the Institute for Fiscal Studies. We will move straight to questions.

Good morning, panel. Audit Scotland has highlighted that waiting time standards

“do not provide a comprehensive picture of postpandemic service performance or recovery.”

What additional measures or indicators could offer a more comprehensive assessment of healthcare performance and recovery post pandemic?

The centre for sustainable delivery’s work is about redesigning services and looking at alternative ways of delivering services. That means understanding changes in the data and then understanding what might be helpful in respect of changes to the indicators. We need to understand the impact of that work before we can say what it might look like, but there are opportunities. We are focused on redesign and considering the alternatives.

The existing cancer waiting time target has not been hit for 12 years, and that is difficult for cancer patients; you can imagine the stress of waiting for diagnosis and then going through cancer treatment. Therefore, although I understand that it is always good to get more and broader data, the 62-day target being missed is quite a clear example of where the health service has been going wrong.

The last time that we hit the target was in 2012, and the situation has been getting worse every year since. In fact, at one point last year, only 69 per cent of cancer patients were seen within the waiting time target. Staging data shows that far too many Scots are diagnosed with cancer at stages 2, 3 and 4 and not at stage 1, and then people face a further delay for diagnostics and the beginning of treatment. Although the 62-day target is not perfect, it being missed is a strong indicator that something is going badly wrong in cancer services.

We have staging data and cancer incidence data, but it is important that we hold the Government to account on the cancer waiting time standard. In the programme for government, which was published last September, the then First Minister called for demonstrable improvement in cancer waiting times. I would welcome the committee seeking to understand what that means. We would like to know more about that. That target was meant to be hit by April 2024, but it has not been met. What does “demonstrable improvement” mean for cancer waiting times?

I will follow that up. As a cancer surgeon, when patients in my clinic ask me when their operation will be or when they will have their staging scan to judge whether they have secondaries, that is a very difficult conversation to have, because I might have to tell them that, for example, based on the data from last week, the diagnostics waiting times for CT scans have increased by 20 per cent and the waiting time for MRI scans has gone up by 7 per cent. Each of those people is part of a family, and there is anxiety for them. There is also anxiety for clinicians, because we are trying to deliver care, but we cannot deliver the high standard of care that we have been trained to deliver.

How do we balance the need for accountability and the need to capture high-quality data, and how can we have flexibility to adapt and improve indicators and targets? I take on board that many of the targets are not being hit at the moment. How can we use the data so that things are more realistic for people?

The issue with targets and indicators is that it is key to have the right target and to understand exactly what it is measuring. As Peter Hastie said, we can get an indication of the direction of travel from the targets. None of the targets are perfect, but they tell us when a system is failing, and we need to look closer at the system to try to determine—along the entire patient journey—where those failures are. Although imperfect, they tell us to look closer.

The issue with meeting some targets is that doing so will detract from other patients, such as non-cancer patients and patients who are on waiting lists for operations that seriously affect their quality of life—knee replacements and pelvic floor surgery for incontinence, for example. We must be able to look at the entire picture and get an indication from a target, rather than making the target front and centre ahead of everything that is peripheral to it.

Is there any data that we should be capturing to inform the targets and indicators that we are not capturing now? If there is, what data should the Government capture?

Part of our day-to-day job in the centre for sustainable delivery involves working across all health boards in Scotland. We need to understand local data collection as well, because certain data points are reported through national data sets, and then as systems change, processes change locally and pathways change, we need to update the data recording so that we understand and are able to demonstrate what is happening in different services.

As we modernise ways of delivering services, we need to modernise the data sets in order to understand the pathways and the impact that they have on patients. That work with health boards is on-going. It aims to support the discussion on standardisation across Scotland in order to reduce variation in the data collection.

I declare an interest as a practising NHS general practitioner.

More than 840 Scots are on waiting lists currently, one in three cancer patients is not being seen within 62 days and out-patient waits of more than one year have gone up by 11,000. If we look at our workforce, there are more than 4,000 nursing vacancies in NHS Scotland, and whole-time equivalent GP numbers have decreased by 42. Katie Cuthbertson, why are we not seeing significant improvements?

The work of CFSD is focused on improvement opportunity and on working with health boards to understand the particular challenges across the pathway. The CFSD is commissioned to work on the earlier cancer diagnosis element of cancer work.

As an NHS unit, we work across Scotland with all services, identifying where particular challenges are. Diagnostics—whether diagnostic imaging or scope-based diagnostics—which have been mentioned already, is one particular area. It is about using the framework for effective cancer management and considering all the identified opportunities. Critically, it is also about learning from what is working well in one service in one health board and sharing best practice to avoid reinventing the wheel or duplicating effort each time a board looks to redesign and implement changes.

That is what you are trying to do, but I asked why we are not seeing improvements. That work has been going on and it sounds great, but what is the product? What is the big benefit that we have had?

We are seeing improvements in services that are implementing those redesigned ways of working. Our job is to translate them across Scotland; to share that best practice as a national team, which helps boards to implement that practice quicker; and to make visible data on where changes are impacting positively on patient journeys, in order to share that learning quickly across our networks. We work weekly and monthly with clinical leads across all services, looking to transfer that learning.

It is absolutely about transferring opportunities into benefit for patients, and we in CFSD will continue to focus on that work across all the different portfolios.

Max Warner wants to come in on that question.

There is also a broader context here, which is that the NHS as a whole is struggling to recover treatment volumes. It is not just about cancer services; it points to quite a large productivity challenge in which there is additional funding and staffing relative to pre-pandemic levels but no corresponding increase in output. Indeed, most treatment volumes for other parts of the NHS are below those levels. That broader productivity challenge plays a role in the challenges with cancer and elective waiting times.

Good morning, panel. Thanks for being with us. I would like to ask about unmet need post-Covid-19. To what extent is there unmet need and hidden patients?

Nobody was prepared for the pandemic. When I think about cancer services in particular, although the bulk of cancer surgery, when it did in fact take place, was successfully carried out despite fairly adverse conditions to the health of patients and, indeed, the health of staff—which I think we should be proud of—we know that patients did not come forward and present to their GPs. I have seen several patients who, when phoning up their surgery, got the Covid message, did not wait to make an appointment and presented six to eight months later. We are probably only starting to see the tip of the iceberg with regard to patients who did not come forward. That was coupled with a pause in screening and in pretty much all diagnostics, so we have been left with a huge backlog and we do not really know what the magnitude of the unmet need is.

Thank you for that answer, Professor Din. Do you have any notion of which groups of people were more likely to not come forward? We can probably intuitively guess which ones those will be. Are we talking about older people? Is there a greater impact on access to that first line of care for folk from areas of greater deprivation?

It is both those groups specifically. The older population, for instance, does not want to make a fuss about troubling anybody—whether that is doctors or primary care. Equally, in areas of lower socioeconomic wealth, the magnitude of impact is much greater. In fact, we will see—and we are seeing—a worse divide in health inequalities, which is secondary to Covid.

The reality is that, as the work that Cancer Research UK has carried out shows, patients know what the red-flag symptoms are—they can recognise 12 out of 15 of them—but they do not seek advice for them, which is interesting. In fact, a lot of work needs to be done on public awareness and allowing patients to access services.

I am afraid that it comes down to investment. We need more investment in services across the piece.

09:30  

I am sure that we will dig into that in a little while. Peter Hastie, do you have any reflections on those questions?

I will add to the point that you and Professor Din made about the point of need. Cancer patients vary in their needs. We think of cancer patients as a group, but, as you suggested, there is a group of cancer patients with far greater needs. Macmillan has been working in partnership with the Scottish Government to transform care after treatment across Scotland. By the end of this year, our partnership should reach every cancer patient in Scotland to address their wider holistic needs.

We want to add to that sense that some patients have far greater needs when they are diagnosed. Of course, all cancer patients need to be treated as quickly as possible, but for some patients we would like to see much earlier person-centred care intervention to try to stop repeat journeys to hospital or to accident and emergency departments. If we can put in place much more social care support for people with comorbidities, that can prevent difficult episodes from happening. Not all cancer patients need the same level of support, and we think that if we can, in partnership with the Scottish Government, bring in that early person-centred care intervention, it could save the NHS a huge amount of repeat visits and return journeys.

That is hard work, however, and it involves shifting the nature of the workforce. It is not additional work, but it is about shifting existing ways of working, and we appreciate that that is hard.

Katie Cuthbertson, do you have any comments on the question of unmet need and potential hidden patients?

I do not have any data on that specifically. The work that we do is very much about creating the demand to meet the capacity. We know that there is a demand-capacity imbalance, and all work is targeted at reducing that imbalance.

We are called the centre for sustainable delivery, so we are concerned with sustainable solutions. We know that there will be shorter-term initiatives to tackle the needs of some of the patients who are currently waiting the longest, but we are also working in tandem to implement more sustainable solutions, so that we do not see those waits creep back up thereafter.

That is helpful.

I think that Mr Warner wants to come in.

Yes, I was just going to ask if he wanted to come in on that.

I want to provide some numbers, as we have looked at the issue a lot. If we look at the elective waiting list, which covers most pre-planned, non-urgent care, and compare what happened before the pandemic with what has happened to referrals over the past four years, about 1.5 million pathways have not occurred—that is, 1.5 million people have not even been referred. That is not 1.5 million people not being treated—it is people not even joining the list. That is a huge number.

What is most striking is that there has been no sign of those referral numbers bouncing up. Even now, for the elective waiting list, referrals are still about 10 per cent below pre-pandemic levels. I do not think that anyone here thinks that underlying need is still 10 per cent below what it was, especially given the missed referrals.

Cancer is a slightly different, and more positive, story, as we see referrals rising more or less in line with pre-pandemic trends. For the elective waiting list, however, more than a million people were just not referred at all in the first place during the pandemic.

In your answer to Sandesh Gulhane, you touched on productivity. Will you give us a notion of what factors might have contributed to the fall in hospital productivity, as reported by the Institute for Fiscal Studies?

Absolutely. The first thing to say is that this is not a Scotland-specific problem. We see an almost identical fall in productivity in English hospitals so, as a first pass, that is not just a policy failure but a fundamental challenge that health systems are facing.

There is a range of potential explanations. Currently, one of the leading explanations is what we, as economists, would call the input mix. By that, I mean that, since the start of the pandemic, we have seen a big increase in the number of front-line staff. The NHS in Scotland now has more doctors and nurses, for example, than it had before the pandemic. However, we do not see a corresponding increase in the other things that matter too, such as capital spending and hospital beds, among other areas.

That is part of the challenge. Another part is that it is likely—to come back to the issue of higher or unmet need—that patients are just coming back sicker and needing more care. Even if you are treating fewer patients, therefore, you may well still be delivering more care. Ultimately, there is a range of potential explanations, and there is still very little evidence of what is driving the situation, but the issue is a major challenge.

Do you have any reflections on what can be done to address that? You have spoken about reductions in capital spend. How would you respond to that?

Our view is that capital spending is important. You could make an argument that it has perhaps been underprioritised, given the pressures that health services across the United Kingdom have faced. That is one area that we would be focusing on. There is still not really conclusive evidence on that issue. It is a major issue, but we still do not have perfect answers.

That is helpful.

I wonder whether other panel members have an opinion on the impact of the budget pressures that everyone is facing and about the pausing of capital spending—of spending on capacity, I guess.

I had a quick look at last quarter’s cancer waiting times. When Shona Robison was health secretary, Macmillan campaigned successfully to get each health board to state why it had missed the cancer waiting times target, and that was helpful. In December 2023, the Ayrshire, Dumfries and Galloway, Forth Valley and Lanarkshire health boards all said that they had had scanner breakdowns or problems with their scanner equipment. That is a straightforward example.

I wonder whether the committee could ask the Scottish Parliament information centre to do some research on all the previous quarters’ data. I can tell you what happened in the most recent quarter, but if SPICe could collate across the past four, eight or 12 quarters, you would get a fuller picture. For instance, in the most recent quarter, scanners have been mentioned four times by four different health boards, and my guess is that that would probably be repeated. Other health boards say different things, but if somebody could do the research to pull all that together, it might give you some of the answers better than I am able to do today.

Professor, you spoke about the impact on other conditions. I guess that MRIs and CT scans are not just used for cancer treatment, and that element will have a knock-on effect across the board.

Yes, absolutely. That is not news to anybody in this room. The increase in the rate of referrals is and has been exponential, and that is still without all those missing referrals that have come through. You cannot expect delivery of an adequate standard of healthcare with fewer resources, fewer functioning resources, less infrastructure and a workforce that does not have all the key components—nursing staff, doctors and all the allied health professionals—that build the system and allow it to work.

Before we move on, I will make a declaration and refer to my entry in the register of members’ interests. I hold a bank nurse contract with NHS Greater Glasgow and Clyde.

I am a little bit confused. We seem to be getting pieces of evidence that run counter to each other. Mr Warner spoke about decreased productivity with increased staffing levels, but Professor Din is saying that there is a lack of resource. I am keen to find out whether the issue is one of productivity. If so, what is the centre for sustainable delivery doing in that regard? I cannot see anything in your submission on that. Is it about increased demand? What do we think is driving that?

I am coming at this simply as an end user—as a surgeon who works on patients with cancer and patients without cancer. We can see that we do not have enough staff to see patients in secondary care with the demand from referrals from primary care. That is a straightforward fact. We know that patients are waiting longer for their investigations and to access surgery. Importantly, that is not just for cancer surgery; it is for surgery that affects a lot of angles of quality of life. That is my view as an end user of our system.

Is it about productivity or the efficiency with which services are run? I open up that question more widely.

Our work in CFSD is very much about seeking to maximise the use of our resources, so it looks across the various component parts of the pathway. Workforce challenges can vary across different services, but we explore opportunities for using alternative service models.

We work closely with NHS Education Scotland and NHS Scotland Academy to examine accelerated models to upskill staff. For example, that could involve alternative workforce models for nurse endoscopy or working with boards from day to day to identify opportunities and support their implementation. Therefore working across a number of areas, including productivity, and maximising our resources are very much part of what we do in CFSD.

Is there a specific workstream that explores productivity as opposed to service redesign, or is that a thread that runs through your work?

We would see it all as part and parcel of everything that we do, not just in the cancer workstreams in CFSD but across all our workstreams. Exploring what more we can do is a thread that runs through every bit of our workstreams.

Does it cover not only staffing but other resources?

That depends on whether you mean resources such as CT and MRI scanners, or staffing resource, in which we explore how we can support staff through using alternative health technologies to help services to be more efficient. For example, as an alternative to upper gastrointestinal endoscopy for certain patient groups, we recently introduced sponge technology, which this year became a business-as-usual approach. Because that is a nurse-led service, more patients can be seen in one session than would be the case with traditional upper GI endoscopy. Therefore we are also exploring where we can introduce technology to help services to be more productive.

When do you anticipate that you will start to see that being reflected in waiting times coming down, either for diagnostics or for patients waiting to be seen?

As we roll out those models and embed those ways of working, we start to see improvements. We cannot yet say that we are seeing maximum benefit from some of those initiatives. When services have introduced and embedded them as business-as-usual approaches, we are seeing improvements in shortening patient pathways. As you will know, however, it is not just about one component part but about bringing together many such parts to give us the overall gains.

I want to come back to what Peter Hastie said about it being good to have the data from previous quarters. That is such a basic point. Why is the centre for sustainable delivery not providing that data? Why would you need to come to us and ask SPICe to do that research? To me, everything is about the data. Perhaps Katie Cuthbertson could answer Peter’s question about why the data is not there.

We are a commissioned body of the Scottish Government, so I do not represent the Government. The Scottish Government has certain data and we focus on improvement data and understanding what is changing as part of service redesign. However, I will be happy to have a further discussion or to provide further information after the meeting.

So you do not have the performance data to look at sustainable development. I am just wondering how you can do sustainable development if you do not have basic data.

Sorry; yes we do have that. I thought that you were referring to the particular issues in boards around—

I was asking about Peter Hastie’s question about looking back at the quarters when the kit broke down.

I could not comment on that specifically today, but we do have access to the published performance data and we examine it regularly to help us to understand where the challenges are.

Therefore we do not need SPICe to produce that data, because you say that you can produce it.

We can look at doing that. I thought that you were making a point about particular capital.

Thank you.

Good morning to you all. I am interested in the good work that is being done on establishing rapid cancer diagnostic services. They were launched in Dumfries and Galloway, Ayrshire and Arran, Lanarkshire and the Borders in 2021, since when the uptake for bowel cancer screening seems to have become the highest ever in Scotland.

On 30 April 2022, there was a 67 per cent uptake in people returning their bowel screening kits, which is the highest in the programme’s history. Do we have enough data about breast screening, bowel screening and other screening uptake and how that leads to the requirement for intervention? I am looking at Katie Cuthbertson, because I got most of that information from the centre for sustainable delivery.

09:45  

Although the screening programme sits separately from the CFSD, we are working in partnership across all the different partners to understand clearly how the elements that we are focused on—earlier cancer diagnosis and pathways within boards—need to be adapted to accommodate that. I do not know if that is particularly the case with rapid cancer diagnostic services, but, as you say, a number of health boards have introduced those in the past 18 months, and there have been positive outcomes from it.

Research recently published by the University of Strathclyde shows that more than 96 per cent of patients were satisfied, and the rating of services was eight out of 10 or more. Similarly, in primary care, positive feedback on those services was received from clinicians.

For patients who do not have specific symptoms and may not fit neatly into one particular pathway, we are opening up the opportunity to refer them to that one-stop rapid service to make sure that patients are not waiting for that diagnosis longer than is absolutely necessary during a very anxious time.

I must remind everybody that I am still a registered nurse, and I worked in the operating theatre and recovery room in NHS Dumfries and Galloway. I am looking at information that says that patients are sicker than they were pre-pandemic and that they have multiple comorbidities. How does making a patient ready for surgery affect waiting times and preparation? Is that a factor that we need to think about? I see Peter Hastie, Katie Cuthbertson and Professor Din nodding.

I come back to your previous comment about screening, particularly bowel screening. We know that cervical screening uptake has decreased. It is important to focus on that area to try to understand the drivers behind that decrease.

Thanks to the faecal immunochemical test, which is an easier test to do than its predecessor, the uptake of bowel screening has certainly improved, but I will comment on bowel screening and on the threshold set for bowel screening. For bowel screening, we screen patients at 80 micrograms of haemoglobin per gram of faeces, but in fact the test is positive at 10 micrograms. We know that screening capacity, or rather the threshold, is titrated against the endoscopy capacity to test positive results. If we want to detect cancer early, there is an obvious way to do that with the system that we have, by thinking about models that lower the threshold. I have led work on that in our region. We know that we will miss that around 35 to 40 per cent of patients will have had a positive test but they are not at the threshold for colonoscopy.

The knock-on effect of that is that patients are falsely reassured. Patients then come to clinic within that two-year period and say, “I did my bowel screening six months ago, so how come you are telling me that I now have a bowel cancer?” There is a lot of work to be done on thinking about how we address capacity issues with bowel screening. Uptake is good, but we could detect more cancers.

On your question about prehabilitation, an important piece of work is being done and rolled out. We know that if we can make patients fitter for surgery, their overall outcomes are better. When we have a cancer timeline with a patient who is potentially symptomatic from the cancer itself, it is a balance between what the gain is versus further symptoms due to the cancer, but it is certainly important to optimise patients for surgery and improve their fitness, and resource in that area is certainly welcomed.

You said that cervical cancer screening uptake has reduced, but I am aware that there is self-sampling research going on now, and there is also research about urine testing for the human papillomavirus. Would that help? It is less invasive than traditional screening, so can we chivvy along that research so that we can also use either self-sampling or urine testing to screen people?

Yes. There are a few folk in the room who will have had a smear and will know that nobody looks forward to it. Any research that can lead to a different test is important.

That brings us on to the question of how we drive innovation. In my view, it is through increased investment in research endeavours in partnership with research organisations and universities to consider innovative solutions within a constrained model of finance.

I refer to something that Professor Din was talking about: the qFIT, or quantitative faecal immunochemical test. One issue that I have in primary care is that I do not have access in all the different health boards to request tumour marker tests. Aside from tumour markers, one condition that probably has a worse outcome than cancer is heart failure, and I cannot request a proBNP everywhere. Surely it would be a good first step in detecting those things earlier if GPs were able to request such tests.

Absolutely. That is a good point. When it comes to the sensitivity of tests, in some of the discussions that we have had in secondary care about whether some of the tests that are available have low sensitivity, we have found that a positive test has the danger of generating a lot of referrals in itself. I cannot particularly comment on proBNP and its sensitivity, but the key thing that comes across is that everything needs to be done in partnership, not in silos.

As for primary care and secondary care, we rolled out our qFIT within secondary care for triage—which resulted in a decrease of about 60 per cent in new colonoscopy requests—in conjunction with our primary care colleagues and colleagues in gastroenterology, radiology and management. That shows us that, if we align everybody’s priorities and what they want to achieve, we can get a new model of activity.

I would say that the conversation about proBNP is for you to have with secondary heart-care specialists to determine the best model that will help you with your patients in primary care.

It is the standardisation that is the problem. I can request a proBNP in some places, while I cannot do so in other places. As a surgeon, how many sessions are you personally operating, on average?

Most surgeons will probably say not enough. Some work is being done to potentially think about other administrative roles that clinicians have—not just surgeons—and whether some of those administrative tasks can be removed so that they can undertake more clinical duties, whether it is surgery or seeing new patients and out-patients, or indeed performing endoscopy, in my line of work. It is about utilising the skill set to people’s best ability.

You are right. Lots of friends of mine who are orthopaedic surgeons say that they are over the moon if they have an all-day operating list. They do not get to operate as an orthopaedic surgeon or general surgeon. I used to be an orthopaedic trainee, and those guys train so that they can operate. If they are just getting a day a week of operating time, that is simply not good enough. It is not the fault of the surgeons. They are desperate to operate, but many of them are not getting to do so. If you are not getting into theatre to operate on patients, how on earth can we clear the backlog?

You have posed the question that I would pose to the committee. You are absolutely right about having a workforce with the right skill set but not utilising it to capacity.

The issue with access to theatres is not necessarily that there are not enough surgeons; it is more about the entire infrastructure and the entire team being able to deliver surgery safely. That will be the case across all the various strata and types of surgeons. We are in our happy place when we are operating. If you look at the model in this country versus those in others where surgeons operate three times per week, you will see that they are very different.

You have answered a lot of questions about cancer treatment waiting times, and we have said a little about pre-operative screening. I would like to pick up on what Sandesh Gulhane said about the perioperative environment, I have worked there, so I know that you need lab and X-ray support, recovery rooms and pre-operative support. That is why elective surgeries are not done at 10 o’clock at night. The capacity of the perioperative environment depends on the wider team. I know orthopaedic surgeons who would be really happy to just do arthroscopies and hips and knees all day, but the wider team is required for those.

Where should there be improvements? What could be done to improve cancer treatment approaches? We have addressed the diagnostic part, but then there is intervention. We might need more CT scanners, but we also need people to read the scans and diagnose patients from them. The situation is complex, but can you suggest anything that could be done differently? I will come first to Katie Cuthbertson and then to Professor Din.

I go back to the point about making the best use of our resources. On the perioperative pathway, we must consider how we can support surgeons when they are in theatre and have a full-day list, such as by ensuring that sessions are scheduled appropriately and getting as many patients operated on in one session as we can safely manage. Initiatives such as rolling out our theatre scheduling tool across Scotland to increase efficiency in theatre time allocation, and exploring opportunities for digital pre-op assessments will streamline that pathway for patients.

That links to the point about optimising patients prior to their going to theatre and then supporting optimised post-operative periods. CFSD’s perioperative delivery group is conducting a number of workstreams, including one on workforce opportunities. For example, as you will know, theatre staffing can present challenges, in that various staff need to be present at any one time. We are exploring opportunities to upskill certain staff groups to support theatre teams to ensure that we can be as productive as possible in those theatre slots.

It is challenging to come into work wanting to operate but then to have to tell a patient that we cannot do their operation that day because of capacity issues. I would therefore very much welcome an examination of the entire pathway. For patients who have previously fasted, then come in for their operation and got into their gown, it is the worst thing possible to be told, “Actually, we are cancelling your operation.” There is a metric by which we can measure efficiency and productivity through the number of cancellations across the boards.

10:00  

I declare that I am a fellow of the Chartered Institute of Personnel and Development. I am gobsmacked by what I have heard. The issue is crying out for a work study to be done, to look at efficiency. It makes you wonder why we are not all over this. A work study should have been done, and one needs to be done with urgency. As Professor Din said, the entire pathway needs to be examined, so I am delighted that, as a committee, we are addressing the matter and treating it as important.

I have two questions on the theme of the barriers to meeting cancer waiting times. In its “NHS in Scotland 2023” report, Audit Scotland said:

“Meeting waiting times standards for cancer remains a priority, but performance against the 62-day standard is poor”.

Peter Hastie, you said:

“something is going badly wrong”.

What do you think are the main barriers to putting the wheels back on the bus, or—given that this has been an issue for a while—to putting them on the bus? We have talked about the fact that the surgeons just want to get in there and do their surgery. What are the other main barriers to meeting the waiting time standards?

As I suggested earlier, the statistics are there—we get them every quarter. They are very varied, but I think that they can be split into two. The first barrier relates to equipment. Obviously, there are technological advances all the time, but we need to have the basic equipment, which needs to be funded. Secondly, it is clear that the workforce planning has not been done. I have been working in cancer for 15 years. I do not think that there is anybody out there, in any statistical analysis, or any politician who does not know that the baby boom generation that we had after the second world war is getting to an age at which most people have a chance of getting cancer.

I appreciate that cancer is changing. As we saw this week, lots of under-50s are starting to get cancer, but, by and large, we understand cancer to be mostly a disease of ageing. We have known about the ageing population for an incredibly long time and we have simply not put in the workforce planning to deal with that. I am talking about the workforce across the board. There is no simple solution. Each health board has a different workforce issue every quarter. Different health boards have different issues, so I cannot point to one type of workforce that is needed. The answers are simple, but there are issues across all types of workforce.

I want to ask you about the equipment issue. Is the equipment not there or is it simply the case that it is not maintained, so it breaks?

The stats say that it is a mixture of both—equipment breaking down and a lack of capacity, which means that people are not able to use the equipment.

Is the equipment old or is it breaking because it has not been maintained? Perhaps you do not have that data.

I do not know. It seems to me that it is a mixture of both.

If the kit is not working, we need to ask why that is. That needs to be looked at.

With regard to workforce planning, each individual health board seems to do its own workforce planning, but we do not have a holistic Scotland-wide workforce plan. The danger of that is that we rob Peter to pay Paul. People might flock to where there are specialists in, say, cancer treatment, which creates an issue. Would you say that having a holistic workforce plan is a massive priority?

Absolutely. I think that the three cancer networks try to pull together across the boards, but the fact that all 14 health boards have different capacity and different challenges at different times clearly causes a major problem. We must face up to the fact that Scotland has a huge rural and island population, which makes things very difficult. People do not support the centralisation of services. Members all know that from their constituencies.

So we need to have a workforce plan.

I would like to go to Professor Din, who was nodding. We talked about the fact that surgeons are in their happy place when they are doing surgery. What other barriers are there?

Without wanting to say the same things again, I think that it is a case of having the allied health professionals and infrastructure in place and having kit that is fit for purpose.

If we think about the capital investment that is required to keep hospitals running, we know that they have maintenance bills that are off the scale. All the little segments of time that are consumed with, for example, information technology, such as getting an old computer to start up, add up and that increases the lag within the system.

System-wide, I do not have a quick solution for that but, to my mind, it is really important that we have a workforce that we can recruit and retain in Scotland. Surgery is one thing: we know that, for at least 32 per cent of all solid cancers, surgery is the mainstay of treatment. Providing that we detect cancer early, that is the best way to afford a cure for those patients and, indeed, improve the economy by having a workforce that is in work.

It is not just about increasing the workforce in isolation. We also need the equipment for the workforce. For example, we need to have enough CT scanners to meet the demand that is created by referrals from primary care as well as from emergency presentations. We know that around 20 per cent of all cancers will be picked up through the emergency pathway. Any flicker of change in that percentage is a good barometer of how well we are doing.

However, emergency presentations of cancers have not decreased and there has been no real change. We know that screening will detect around only 7 per cent of all cancer, so there is a huge gap of symptomatic patients that fall in between. As secondary care clinicians, we need to work in partnership with primary care providers to address that gap and work out how to enrich the response to serious symptoms that can then be filtered into constrained diagnostics.

So, overall, we need a Scotland-wide plan and we need to make sure that the kit is there and that it is properly maintained. I know that this may sound like a basic question, but in your view, what impact do longer waiting times have on outcomes for cancer patients?

I will start by talking about the impact on mental health, because I think that that is absolutely critical. Anyone who has cancer wants it to be treated or operated on the next day—that is in our nature as humans. The uncharted impact on mental health for patients, their families, the clinicians and other healthcare givers who work with those patients is huge. As patients wait longer, they will potentially be more deconditioned and frailer, which will increase the risk of any treatment, whether that is surgery or chemotherapy, and potentially there will be more complications.

The impact of increased waiting times is not to be underestimated on many different levels, including mental health and physical health. That results in an opportunity cost in other non-cancer areas that we would not be addressing.

In your view, what further action is needed to target improved outcomes? If you were the Scottish Government and you could work on a plan for this year and next year, where would you focus the targets, effort and resources?

I am not the Scottish Government. From my perspective, we cannot treat our way out of cancer. As you mentioned, we know, because we have an ageing population, that in approximately 15 years, there will be an increase in cancer cases of around 30 per cent. CRUK has clear data with various projections and there is also data on that in Scotland’s cancer plan.

Therefore, we have to think innovatively and, in order to do that, the investment has to go into research and evidence-driven initiatives to improve cancer outcomes. For every £1 invested in research, we get a £2.80 return, and, as we get an increase in the prevalence of cancer, you will get a return on that investment into cancer research for the health of the population.

For me, the focus would be on research investment, which is not just basic science but outcomes research. We cannot work out where things are going wrong if we do not have real-time outcomes research so that we can actually detect the performance of a pathway in real time.

What role, if any, does the centre for sustainable delivery have in workforce planning?

We do not have a role in workforce planning specifically. Through our structures—such as special delivery groups—we work with a number of specialties, looking at high-impact opportunities to make changes that will positively impact on patient waiting times. That involves working with clinical and operational management leads from all health boards who come together to discuss specialities, such as respiratory medicine and cardiology.

Workforce opportunities might be identified as part of that work. For example, if one health board is implementing an alternative workforce solution with regard to a theatre team and how roles are being upskilled in theatre settings, we would work with our partner organisations, such as NHS Education for Scotland.

I do not mean to be rude but there is an awful lot of management speak in there.

I am sorry.

In essence, you do not have a role in workforce planning—

No, not in management and planning, but we contribute to the overall work that that leads to. Our work is more about identifying the opportunities, what impact those might have and then being able to show data to represent that, but we would not do the overall planning piece.

So you input data.

We would be able to share data and share what boards are doing locally around redesign, how that is impacting positively and how that might contribute to a broader strategy in the future.

I have some questions about early cancer detection. Coincidentally, I had to take a call from a consultant just now, so some of my questions might have been covered while I was on the call. What factors contribute to longer waits for diagnostic tests and can you outline how those factors can be overcome?

I am happy to start. Earlier, we talked a wee bit about diagnostics. As we know from the data on some of the waits, the delivery of diagnostics contribute to a reduced performance on the 62-day standard. The work on diagnostics is looking at how to maximise and make best use of some of the infrastructure but also at staffing models in support of the delivery of diagnostics. For example, in scope-based diagnostics, we look at how we can use alternative workforce models, such as nurse endoscopists, endoscopy assistant practitioners and so on, and offering more outpatient-based diagnostics as an alternative to scopes for certain patient cohorts, which will help to free up capacity for patients who need to undergo particular tests. Offering alternatives for other patients cohorts will speed up that journey.

What progress has been made to ensure that rapid cancer diagnosis is available across the country, and what more needs to be done?

We have the Strathclyde report, which was published earlier this year. Earlier, we touched on some of the positive outcomes that were demonstrated in that report. The CFSD will continue to work with boards and to share that learning and the positive impact that that work is already having in some boards across other boards in order to support implementation across further services and open that up to more patients across Scotland.

You will also have discussed this earlier, but what impact has Covid had on the stage of cancer presentations. I heard a wee bit of an earlier response but my mind was elsewhere.

10:15  

I think that we are still waiting to find out, Mr Dornan. There was the six-month delay in the screening programmes, so this year’s cancer staging data might give us a better picture. Unfortunately, Public Health Scotland, unusually, has not set out when the cancer staging data will come this year. We are still waiting for cancer mortality stats from last year, and there is no indicator of cancer incidence or mortality or staging data for this year. We really need Public Health Scotland to publish those figures, which would give a better indicator.

No doubt your question alludes to the fact that people will have been getting diagnosed later, which adds to the huge pressure on the cancer workforce. The later somebody is diagnosed, the more strenuous the efforts, the more intensive the surgery and the longer the chemotherapy and radiotherapy sessions, which all then add to cancer waiting times. In your area, Greater Glasgow and Clyde NHS board said last month that there was significant pressure on diagnostic procedures. There is a backlog that is building up, and my fear is that that will push people into later-stage diagnosis, with all its subsequent effects.

So before we can move forward, we need to find out what has been happening in the past, so we need to get those stats from Public Health Scotland.

Absolutely, yes.

Okay; thanks very much for that.

Thank you to the witnesses for their contributions so far. We are looking at the factors that contribute to longer waits for diagnostic tests, which certainly chimes with what we heard from oncologists, who said that it is agonising for them to watch patients go from diagnosis to a terminal situation.

What factors are contributing to that, what progress has been made to ensure that rapid cancer diagnosis is available across Scotland, and what more needs to be done?

I will start with the broader picture and go back to what Emma Harper said. We have seen really excellent bowel screening uptake—it is getting to 66 or 67 per cent, which is the best ever. However, that still means that a third of people are not sending back their kit, and I wonder whether we need more innovative ideas—I will leave that up to you—about how more pressure could be put on and how we get a better understanding and provide more support for people.

At the same time, Fife, for example, has exactly the same take-up as the rest of Scotland, but only 50 per cent of Fife men in the lowest 20 per cent of incomes are returning the kit. There is therefore also a massive socioeconomic divide in screening and until we really challenge that and get people in all income levels up to 67, 70 or 80 per cent uptake, we will always have horrendous economic factors. We need to look at the social justice element of cancer far more closely, because far more people from lower income groups get cancer, get diagnosed later and have worse outcomes.

That certainly chimes with an experience that I had visiting a Marie Curie hospice in Glasgow, where I met a lady with throat cancer. She lived in Bridgeton, in the east end of Glasgow, and she expressed her devastation that, on presenting to her GP, she was fobbed off repeatedly. By the time she got a diagnosis, it was terminal, and she was only in her early 40s. That was quite harrowing. She died the day after my visit.

What practical steps can we take to address that? Is it an attitudinal or cultural issue? Is it a practical thing? Is there a means of better escalation for patients who feel that they are not being listened to? Is it purely about patient agency? What other aspects could we consider?

It is challenging because of the pressures. I am a secondary care clinician, but I know that the pressures on primary care are phenomenal with regard to the number of patients they see. For each patient who is seen and has a misdiagnosis, there is a huge number of patients who have been seen and have been treated effectively and efficiently. The question is, in the vast thousands of patients who are seen, how do we strive towards picking out patients who have the symptoms that need to be escalated?

I come back to the idea that we need more research into primary care and symptomology. If we had access to the data around patients in multiple areas of the whole natural experiment that is the NHS, and if a research culture were embedded into the NHS, we could ask questions at scale, such as what the likelihood is of somebody having a cancer if they come in with X or Y symptom. However, you need access to all that data.

I would push for something that we can do, which is to try to embed access to patient data and surplus patient tissues and blood, with the appropriate data governance to reassure patients. What Covid taught us is that patients want treatment and want you to use your knowledge to develop better treatments for them. That whole area is challenging for researchers to access in order to generate ideas and answers that can then lead to better early detection strategies.

Is the issue then not just about the structure of GPs as individual contractors, if you like, and their obligations to undertake data gathering and so on, but also about the work that is currently being done to understand where late-stage referrals are happening and whether they correlate to areas of high deprivation, and to then investigate the cause of that late presentation—whether it was frustration with access or simply that the person had not presented until a late stage? Is there any data around that at the moment that will give us an insight?

I could provide further information on that point, following today’s meeting. As you will see in our briefing, the work that CFSD does is about targeting, as well as supporting, those areas of deprivation. Going back to your point, one of the pieces of work is about getting patients on that pathway as quickly as possible.

The refresh of the Scottish referral guidelines for urgent suspicion of cancer is on-going and the update will be published early next year. It is about using that up-to-date evidence to ensure that those guidelines are appropriate for use in primary care. There is also the launch of GatewayC, which is a support platform to help primary care clinicians identify those symptoms, support making the decision about the most appropriate pathway for that patient and get the patient on the right pathway the first time.

Absolutely. For instance, if we looked back at scale to the 20 per cent of patients that present as emergencies through A and E departments or emergency referrals across the health boards, to try to identify how many instances of contact those patients had had with primary care or with emergency services, or whether they had just not contacted anybody in primary care—as we often know that certain demographics do not—having that data would really go some way towards understanding what some of those barriers are.

That is helpful.

I met some GPs in Glasgow, who indicated that even referrals to urgent suspicion of cancer have become a meaningless escalation, because of the scale of the demand. Would you agree with that? If even a referral that is marked as urgent is not necessarily being addressed with the urgency that one would expect, how do we address that issue?

It is deeply concerning. One of the positives and great advantages that we have seen so far with the rapid cancer diagnostic centres is that they have been able to rule out cancer for a lot of people—perhaps only about 12 per cent of patients turn out to have cancers—which is an enormous relief. It might mean that they have something else, which will then head off to a different part of the health service.

It is so important that people are either given peace of mind or are diagnosed quickly and sent to another part of the system. I understand why doctors get frustrated. They send someone for a test, it is not cancer, they come back, the doctor sends them somewhere else and it is not cancer. One of the ideas behind the rapid cancer diagnostic centres is that they will be a one-stop shop and that people will find out. The idea that urgent cancer referrals are not being regarded as urgent is deeply concerning.

As Professor Din said, most people are quite shocked when Macmillan tells them that 20 to 25 per cent of cancers are diagnosed at A and E. That is just horrific and the cost to the NHS is incredible. There is no system within which that is a proper cancer pathway and the financial cost of that is off the scale. I am really concerned that you are hearing that sort of feedback.

Would the cancers that are being diagnosed at A and E ones typically be diagnosed through screening?

There is a lot of stage 4 lung cancer diagnosis, but it happens across cancers. Sadly, too often, A and E diagnoses come very late.

Some of the organisations that run screening programmes for the NHS have said that invitations to present for screening can vary widely across different social and demographic areas. For example, there is a difference between getting a letter and getting a text message. Have you seen differences in how people react to different types of screening invitation?

The detect cancer early programme board would be able to provide that information. There has been some fantastic innovation. That brown letter coming through the door might look like yet another problem. Even members of Macmillan staff have told me they have difficulty getting to breast screening because they work long hours and have stuff to do. Screening is not easy and it is not much fun, so we need innovative ways to get people to do it.

One of the great tragedies of the screening delay during Covid—which is nobody’s fault—was that invitations for bowel screening stopped arriving on people’s birthdays. People used to get them at 50, 52, 54, 56 and 58, so they kind of knew it was happening. My invitations now come at 54 and half, 56 and a half, 58 and a half. I know that the invitation is coming, but it has got away from that pattern. We need people to talk about it and to encourage their friends and family, on their 50th birthday, to use their screening kit. We must make that a much more normal conversation because it is about our loved ones.

It is a hassle to go for screening. Going for breast or cervical screening is no one’s idea of fun, and nor is doing the bowel screening kit, but we must encourage people. I have no doubt that new screening will come on board. We hear about innovative ideas all the time. There are lots of campaigns for lung screening. Screening could also be more targeted at people whose family members have a history of cancer. We could work in more specifically targeted ways to improve take-up.

I have a question about the impact of Covid on late-stage diagnosis and the severity of presentation. Have you noticed an effect? I have certainly heard plenty of anecdotal evidence of that. What impact has it had and what can we do to control and counteract it?

There is no doubt that that is coming through anecdotally, but we are still waiting for the statistics. The Scottish Government, in partnership with Macmillan Cancer Support, has just launched the third Scottish cancer patient experience survey. That survey is in the field now and the results, which will be out in September, will be a huge aid to the committee’s understanding of what happened to cancer patients during Covid, because the cohort is from that period. That might give some of the evidence that you are asking about. We are still waiting for Public Health Scotland to give a publication date for this year’s cancer staging data. That will tell one of the biggest stories and go beyond the anecdotal.

My question is for Katie Cuthbertson and is about IT. Your website shows that you are involved in that. How long have we been trying to get IT systems to talk to each other?

That is not necessarily the work that we are leading on. Our work is on the opportunities to introduce alternative health technologies that may, absolutely, need to talk to other systems within health boards. The work that we focus on is identification of the high-impact opportunities.

Where are the technologies that are available now to purchase in the market? We are not focused on the research and development stage in our work, but what emerging technologies could we introduce into our services to improve waiting times? For example, we have a number that support various cancer pathways. The digital dermatology programme was recently approved for national roll-out. Obviously, that will also support skin cancer pathways. As I mentioned earlier, some alternative diagnostics were introduced, and with the sponge technology now embedded as business as usual, that is supporting scope pathways and reducing waits. Other technologies that are under evaluation at the moment will, I hope, support lung and breast cancer pathways.

10:30  

We will certainly come on to that.

The national workforce strategy refers to

“collaborative working across RCGP, CfSD, Scottish Government, Health Board Interface Groups and other relevant stakeholders to identify new opportunities for redesign of ways of working that can be applied nationally to challenges across the interface. Potential examples for scoping may include referral guidelines, IT, Community Treatment and Care services and unscheduled care.”

What have you done with that IT? Speaking as a national health service worker, it is appalling.

The specific pieces of IT work that we are involved in are around the particular technologies that will help with productivity challenges. For example, digital dermatology will support making the process for GPs to attach images to dermatology referrals much more streamlined and easier.

That is great, but if it takes me 15 minutes to get into my computer in the morning and I cannot access basic stuff from the hospital, and I am not able to access other data sets when I am working in the hospital, what is the point of all of that additional stuff when the basics are not being done?

I cannot comment on that work specifically. I am not involved in that work as part of the CFSD.

Okay. It seems rather disappointing that the strategy talks about

“opportunities for redesign of ways of working”

when surely IT, including basic IT, is the most important way of redesigning for interface.

We work with partners that are involved in that work, but we are involved in specifics around particular patient pathways and where we can support efficiency and productivity in those.

Okay. I turn to lung screening. A number of years ago, I spoke to the then health secretary about the potential for purchasing mobile lung screening CT machines that could go to the north of our country and rural and island areas to provide lung screening at not a great cost. Where are we with that?

Apologies, but that work is not being led by the CFSD. The screening work involves NHS National Services Scotland and the Scottish Government. We would stay connected to any on-going discussions. Obviously, depending on the outcome of the lung cancer screening discussions, we would stay aligned with that, but we do not have responsibility for that at the moment.

You mentioned lung screening in your response to me.

The technology that we are looking at as part of the work within the CFSD would support the lung pathway in the early identification of patients who have had a chest X-ray and may have suspicious symptoms and fast tracking them on to a CT scan for a potential diagnosis of lung cancer. That is the particular piece of work that we are involved in.

Okay. On the NHS’s engagement with technology—I am talking about all technology—what work are you doing to standardise the way in which companies can come in and say, “Let us get approval with either yourselves or with a health board” and not have to do that on a repeated and significantly different basis with all health boards?

That work is being done through partners in NHS National Services Scotland and so on. We are connected when high-impact opportunities are identified that might support some of our most challenged areas with the introduction of the accelerated national innovation adoption pathway across Scotland, which looks at horizon scanning and understanding what opportunities might exist, and working through a pathway to a stage-gate process to essentially assess technologies and understand whether we should be looking at them in Scotland, and then going into more detail about the potential impact, cost effectiveness and so on.

Therefore, you have done that piece of work and you have found that there is a cost-effective piece of technology that is going to work—such as artificial intelligence when it comes to reading our X-rays and computed tomography, as an example. How can somebody get that piece of technology across Scotland in a way that is easy to access that does not involve going to every health board and convincing them individually?

The national team that works as part of CFSD, as part of the ANIA collaborative, is responsible for rolling out digital dermatology, for example. That team will work across all health boards, depending on the procurement process, to procure the particular software and then work on a one-Scotland basis so that there are not different pathways in different health boards. That is the nature of the ANIA work—the word “accelerated” is in the title—to get technologies into the hands of clinicians and benefiting patients much more quickly.

Professor Din, what would be the most helpful technological input in your everyday work?

There are two things, and you have absolutely hit the nail on the head with regard to one of those, in that it is not just about new technology; it is about having fit-for-purpose technology in all the basic things that we try to do, whether that is the IT system through which we try to order investigations or whether we are just trying to use the computer. I completely share your frustrations that primary care data cannot be accessed by secondary care clinicians—and vice versa, to an extent. We cannot see the helpful notes that you have written when somebody has come to see you two or three times beforehand. There must be integration of those systems so that we can access data. Scotland has a rich history in innovation, particularly in data-driven innovation, which, over the past five to 10 years in particular, has come forward with DataLoch and other initiatives.

You need to be able to access data and I need to be able to access data so that we can answer fairly straightforward questions at scale. I will take one specific example of the fact that the focus on cancer sometimes perhaps detracts from other patients. In my line of work, we can think about hereditary conditions such as Lynch syndrome and familial adenomatous polyposis, which carry a very high risk of bowel cancer. We know that people with those syndromes have a much higher risk of cancer than the general population. We have a load of cancer targets for the general population but, because those particular patients do not have a cancer at this point, despite being at extremely high risk of cancer, they fall into a sort of surveillance that is often not fit for purpose. In fact, we are doing a disservice to those patients.

We have made some improvements in our health board to address that situation but, at a very simple level, we need to be able to set up a Scotland-wide registry so that we have the functionality for all the health boards to input their high-risk patients for colorectal cancer or other conditions, because we have identified them as high risk but we then slightly abandon them with no fit-for-purpose system to monitor them. We do not have the IT functionality for all those health boards to link in.

Therefore, if there was one piece of work that I would be very keen to take forward, it would certainly be that—how we can interdigitate primary and secondary care and then do that across Scotland for high-risk patients. That is an example from my field.

It would be good if I could just see another GP’s notes when a patient is transferred.

I will address my final question to Peter Hastie. Professor Din talked about straightforward questions, and the most straightforward questions that I am asked by my patients when they are on a waiting list are, “How long am I going to have to wait?” and “Where am I on that list?” Do you agree that patients should have access to that information? If so, how can we make that happen?

That is an interesting question, because cancer patients themselves are often not aware of the 62-day target. Why should they be? Policy makers know about it, but the patients often do not, although they know that they are waiting for diagnostics and for treatment to begin. We know when the decision has been made for treatment to begin—we are hitting the 31-day target and we should celebrate that.

The question comes back to person-centred care and the need to treat the patient as an individual as they follow their pathway. There was a period when the cancer waiting time targets started to be missed really badly, but Lanarkshire was still hitting them. That was because the health board had focused on person-centred care and on individuals. It had somebody tracking the individual, treating them as an individual, seeing that the end of their waiting time was coming up and booking that space. I appreciate that we are dealing with thousands of people and that what I am asking for is really hard, but if we can focus on person-centred care and give the individual cancer patient the support that they need, we will have far better outcomes. However, you are absolutely right: the cancer patient deserves to be in charge of their journey, and they are not at the moment. Instead, they are sitting waiting for far too long.

I want to ask about technological innovation and the use of artificial intelligence, which could help to reduce bed days, for instance. Last week Dr Tom Mackay, Catherine Kelly and Dr Mary Melville from NHS Borders gave a presentation to the lung health cross-party group, which I co-convene, about keeping chronic obstructive pulmonary disease and asthma patients out of hospital. They showed us that, among that small amount of patients, the implementation of artificial intelligence technology saved 236 bed days and removed the need for patients in remote and rural areas to have to make 50-mile or 100-mile round trips to get to hospital. I should say that patients in the NHS Dumfries and Galloway area have to travel similar distances.

What are your thoughts about the implementation of technology such as AI for out-of-hospital assessments, and can you tell us what other exciting technology is out there? We know that there are research studies about using such technology to examine X-rays to diagnose lung cancer, for instance. I would be interested to hear about something positive as we look at helping our NHS to address waiting times and so on.

Last week, the Scottish Government announced a national theatre scheduling tool. That might not sound like the greatest thing in the world, but it is an example of the sort of innovations that are constantly being made.

You are absolutely correct in what you say. We are all used to using Zoom and Teams, but a lot of older people are not. However, there is a new generation of people coming through who would not think twice about having their follow-up appointment on Zoom, and that approach would remove the need for patients from Dumfries and Galloway to travel to Edinburgh or Glasgow, patients from Orkney and Shetland to travel to Aberdeen and patients from the Western Isles to travel to Glasgow.

There are many innovation possibilities, but it is hard to implement them because people are not used to doing things in the new way and are not used to change, and they might feel that they are missing out on something. However, sometimes I worry about a lack of face-to-face contact, and I do not think that using Zoom and Teams is the perfect solution for everybody.

There is no one particular breakthrough that I can point to immediately, but I honestly do not believe that there has ever been a time of more exciting innovation. As you say, AI can be used to scan data and can spot more cancers than the human eye would. There are amazing possibilities there but, behind it all, you need that workforce to be able to do the scanning and look at the results, and you need workforce planning behind it. If you can marry those two aspects—technological innovation and the workforce—there could be great outcomes. People are living with cancer longer than ever, but we are not detecting cancer quickly enough and, until we get that right, all the other things have to wait.

I have a quick question for Max Warner, as I am conscious that he has not said a lot.

We need to finish this session, so please be brief.

We are running out of time—okay.

Max Warner, you have done modelling around investment in prevention to keep folk healthier. What modelling has been done to show that up-front investment will prevent cancer, reduce obesity and diagnose type 2 diabetes earlier, and have you done modelling that shows that preventing things now will save £X in terms of secondary care?

10:45  

We have not looked at that ourselves, but a lot of modelling has been done on the benefits of prevention and catching things earlier. We discussed that earlier in relation to cancer. However, there is always a need to be cautious in relation to prevention. The motivation for prevention should be that, if you catch things earlier and enable people to avoid developing conditions, that will allow people to live better lives.

The financial motivations for prevention are not always positive, and we should not be driven by them. There is a risk in advocating for prevention only in terms of saving money, because, frankly, people living longer is expensive. However, people living longer is desirable, so we should be motivated to prevent conditions for that reason, not always for reasons of pure financial gain for the Government, because that gain will not always be there, and that is okay: a lot of Government spending is designed to improve quality of life, rather than just prevent future Government spending.

Thank you. The convener is giving me the eye, so I think that I should make that my final question.

I thank our panel members for joining us. We will suspend briefly to change witnesses.

10:46 Meeting suspended.  

10:54 On resuming—