Chamber and committees

Let us take an example. Are you talking about Fife?

We have provided NHS Ayrshire and Arran with tailored financial support because of the pressures that it is facing. If you asked whether issues arise because my predecessor did not make decisions about X, Y or Z, I would say that my predecessor gave a commitment to increase health spending in this parliamentary session by 20 per cent, and we are well ahead of the trajectory for where we should be on that.

The decisions that my predecessor made have increased the investment that is put into health services ahead of what was planned—we are ahead of where we should be. That demonstrates the determination to provide as much financial support as possible and the urgency with which action is being taken to provide additional finance to our boards. In this financial year, there is an additional £730 million and, alongside that, a further £200 million of support.

None of that demonstrates a lack of urgency, understanding or leadership on doing what we can. However, our health service is experiencing the same challenges as other parts of the public sector are because we are going through a period of austerity, which is having a direct impact on the Scottish Government’s budget, and because inflation means that we are experiencing a significant increase in the costs that are associated with running public services, which is having an impact on those services. All of that is having an impact on our budget.

Another point that is worth not losing sight of is that we are still dealing with the pandemic’s consequences. Costs are still associated with Covid-19, but Barnett consequentials for dealing with Covid-19 have stopped, so we now have to meet those costs from core budgets.

Extra money is being provided where it is available, and that is being done earlier and more quickly, which shows urgency. However, alongside that is the fact that we must deal with a range of additional cost pressures, which are having a significant impact not just on health services but across the public sector and in society as a whole—households are also experiencing that in their budgets.

Some of that is geographically specific to your part of the world. For example, one challenge that we have around social care in my area is staff from social care going into areas such as healthcare, because they are more highly paid.

Historically, our social care workforce has been less valued than our healthcare workforce, which is reflected in the rate of pay. That has been the case for some time, and we have to try and address that. We provided additional funding to local authorities to support increases in social care staff pay partly to try to stem the loss of staff from social care into healthcare and other areas of employment where they can get higher rates of pay. We have a commitment to aim for £12 an hour over a period of time, and we are doing some work around what that timeframe will look like.

The other part is that we need to provide good career pathways for those who work in the social care setting, and provide them with opportunities to progress their career and move into other parts of the care setting. For example, someone with considerable social care experience might be interested in doing nursing, but might not necessarily have the academic qualifications that get them into a university place to do a nursing degree.

We are looking at aspects such as the nursing apprenticeship, and we are taking forward that work through the nursing and midwifery task force to look at how we can create pathways into areas such as nursing for people from social care. We want them to see that there is a very clear pathway for them to follow, but we also want to make the social care setting appear as a much more attractive professional setting for staff.

My view is that pay is a big part of that, and we will do what we can to try to help to address the issue, because, historically, social care work has been paid less and had a lower relative value than healthcare work, which has resulted in challenges around the social care workforce.

You will be more aware than I am whether there are shortages of particular labelled medication or their alternatives. We try to encourage prescribing of alternative medications that might serve the same purpose but might not be the prescribed medication that the person had previously been on.

I do not know whether John Burns can say a bit more about other aspects of prescribing. We try to work very closely with the pharmaceutical industry to smooth out issues around procurement and the availability of medication. Sometimes the challenges that we face are, as you rightly say, not peculiar purely to Scotland or the UK. They can be as a result of a worldwide shortage or other challenges. Some of that will be because of stockpiling of medication.

I cannot remember the exact medications, as it was before I had responsibility for health, but I remember some occasions in recent times when there was concern about access to certain medications—in particular, certain forms of antibiotics. I remember being involved in that and hearing a discussion in which the chief pharmaceutical officer was talking about procuring some medications in advance so that we could hold some of them in reserve, if necessary.

It is a matter of planning around procurement of the medication. Where there are concerns around supply chain issues, it can be a matter of trying to stockpile some medications where that is possible. It is not always possible for all drugs, as some of them may have a short shelf life, but it is about trying to manage those things as best we can within the structures that we have, through procurement and with the help of clinical advisers on procurement and the stockpiling of medication. Those would seem to be most appropriate ways to address the situation.

I acknowledge people’s concerns about the delays that have resulted from issues with the water supply and the ventilation system. If anything, though, the fact that those issues have been picked up demonstrates that lessons have been learned. The NHS assure service now has to sign off and approve a capital facility of that nature before it can be declared fit for use, and it has identified deficiencies and addressed those with the board. There are perhaps some lessons for the board with regard to how such a capital project should be managed and how it could possibly have avoided what happened, but the check system that we have in place has caught and identified the issue, and the appropriate measures will have to be taken.

As I have said, if anything, that demonstrates that we have learned lessons from previous experience of facilities that were about to be opened and problems that were identified. In this situation, the problems have been identified at an earlier stage in order to be addressed. Of course, that has resulted in some delay, and it would have been better if that had not happened in the first place. I expect us to look at what we can learn from NHS Grampian’s experience in taking the project forward, but I am reassured that the NHS assure process has captured and identified the problem to prevent its being embedded even further at a later stage in the project.

The burden of disease will continue to increase during the next 20 years by something in the region of 21 per cent, largely because of the demographic shift that we are experiencing as the population gets older. We need to do a number of things to tackle that burden of disease, one of which is to make sure that we are implementing all the right preventative measures to reduce the impact that lifestyle options can have on health. All the public health measures that we take to improve people’s health will be important.

Secondly, we need do all that we can to tackle the social inequalities that drive health inequality, including by tackling poverty and reducing child poverty. Those are key factors in helping to ensure that we focus on preventing ill-health because of social inequality.

Thirdly, we need to continue to develop and adapt our services to meet the increasing demand from older people and people who have multiple conditions so that we can manage their long-term conditions effectively in a way that improves their health and allows the health services to be sustainable.

Prevention is critical, but we also need to adapt our services to meet the increasing demand that we will face as our population gets older. We will also need effective integration between our health and social care services, given that they are critical to one another, particularly in helping older people to manage at home by giving them the support and assistance that they require.

I will probably bring in John Burns to say a bit more about some of the work that we do. The particular challenges that the rural boards face are that they can experience difficulty in recruiting specialist staff because the number of patients that they deal with in some departments means that positions are not so attractive to the staff who need to be recruited to them.

There are a number of reasons for that. For some time now, clinical care has been undergoing ever-increasing specialisation and has moved away from being provided on a more general basis. The general physicians whom we had many more of in the past are becoming fewer and more specialised. That has driven behaviour that results in clinicians wanting to work in specialist centres where there is much more throughput so that they can see the range of patients that they are looking for and build up experience and so on. That is much more challenging in our rural boards, especially given that the population levels are much lower and the boards are not able to sustain the same services.

For a number of years now, we have been putting in place arrangements for managed clinical networks in which we can use clinicians in some of our bigger centres to provide clinical support to boards in our rural and remote areas. Sometimes that involves their going out and holding clinics in those areas, and sometimes it is about supporting clinicians in those areas in their decision making and reviewing of patients. That is one of the ways in which we support our rural and island boards so that they can sustain services. Of course, that sometimes means that patients have to come into the larger clinician centres for specialist care and interventions.

John Burns can maybe say a bit more about some of that work, which has been on-going for some time now.

I do not think that we have ever been at the point where our NHS has been designed; it is a dynamic process and there has always been an element of redesign in our NHS.

I will give you a practical example that I had to deal with in my constituency. Falkirk and District royal infirmary and Stirling royal infirmary both had orthopaedic units, but it became increasingly apparent that, from a clinical perspective, it was not sustainable to have two separate orthopaedic departments. The clinicians said that they did not have the throughput of patients to achieve the teaching hospital status that was necessary to attract junior doctors, registrars and other staff so that the departments could be viable. We have moved from having two district royal infirmaries in the Forth Valley area to having one—Forth Valley royal hospital—which is a single site that provides that function.

It is sometimes the case that redesigns are not driven by the Government wanting to centralise things for the sake of it but are a result of clinical change and clinical demand. The reality is that we are operating in a global market for clinical skills, which means that some services need to be offered in major centres, because they are not sustainable outwith those settings.

I do not want your constituents in rural areas to experience any reduction in healthcare services but, equally, I need to think about how we achieve a balance in being able to meet patients’ clinical needs when it is not possible to get clinicians to work in those areas for the reasons that I illustrated through the practical example from my constituency. In different areas across the country, services have had to be located in a single setting. For example, in the past, we have sought to use managed clinical networks for services such as neurosurgery in Aberdeen. We provided support in Grampian—largely through support from Glasgow and, to some degree, Edinburgh—so that neurosurgical services could continue to be delivered there.

Where clinical expertise and support can be provided by some of our big urban centres to other locations in the country, we have tried to do that and to use that type of design so that we can support rural healthcare. We have used managed clinical networks in some of our Highland areas as well as our island communities for the delivery of certain healthcare services so that we can support clinical services and try to make them sustainable. We will continue to have to be innovative in the approach that we take in an effort to support and retain services in our rural areas as best we can, while acknowledging that there are challenges.

As I mentioned, ever-increasing specialisation is taking place within medicine; it is moving away from the generalist approach that we might have had 30 or 40 years ago. As a result, specialist centres have become more and more important in how clinical services are designed and delivered.

I accept the challenge that exists in your area, and I recognise and acknowledge the concern that you raise. As health secretary, I would not be thinking about redesigning services just for the sake of it and against clinical advice. However, we must recognise that, on occasion, boards have to make decisions on the basis of clinical advice to ensure safe services for patients. We have to take that into account.

We will never get to the point where we have reached a final design—it will always be a dynamic process. We must be innovative because of our large rural areas; we must try to support rural services, where we can, to reduce the need for patients to travel by delivering services as close to people as possible, alongside the increasing specialisation and the need to deliver safe services. We must try to get the balance right, but we might not always succeed and we should not be frightened to admit that—we can revisit such things if necessary. It is a competing balance and one that we have to try to manage in areas such as Tess White’s region.

There is a combination of factors. To go back to the point that I made earlier, one factor is making it attractive to relocate to the NHS in Scotland. I will bring in Stephen Lea-Ross, who can say more about the workforce, but we undertake considerable work through NHS Education for Scotland to try to ensure that NHS Scotland is an attractive employer and that we provide programmes of on-going training, education and support for our clinical staff.

It is worth bearing in mind that we are fishing for these skill sets in a global pool. We have challenges in getting oncologists, ophthalmologists and endocrinologists because there is a global shortage of people with those skills. We must do everything that we can to support and retain skilled people within NHS Scotland.

In terms of medical recruitment into the NHS, in 2022 we managed to fill 93 or 94 per cent of all junior doctor posts, which is the highest number of junior doctors recruited into NHS Scotland since records began. In the last couple of years, we have increased the number of medical places by more than 50 per cent, or 55 places. Is that right?

You seem to have a particular focus on my predecessor.