Chamber and committees

That is a fair question. As per my previous answer on that, we are looking to produce a revised financial memorandum that we will present to the Finance and Public Administration Committee as per its request. The amount that we will spend on the development of the national care service will be a fraction of the overall health and social care budget for the coming financial year. Richard McCallum will keep me right here, but, in the current financial memorandum, the figure is between £63 million and £95 million out of a budget of £1.2 billion for health and social care. We are talking about a not insignificant amount, but it is a small amount in comparison with the entire budget. We will make sure that we do not lose sight of improvements that need to be made right now to social care. We will not wait for the NCS.

The second thing that I would say is that one of the driving forces behind the national care service is precisely to improve pay, terms and conditions and to have sectoral bargaining and ethical commissioning, and to put all of that at the heart of the principles of the national care service. You can see that in the bill. That will make a big difference to the sustainability of social care in the future.

I do not think that we can afford not to. We just cannot. Given the scale of the pressure that we are under, we have to be focused on the preventative as well as dealing with the current demand. Dealing with the current demand, especially over the past few weeks, has been exceptionally exhausting for our healthcare workers, whether they are in community care, primary care or secondary care. They are utterly exhausted after almost three really difficult and relentless years of a pandemic.

I understand why David Torrance asks that question. Part of the solution has to be in the preventative work. We have to make sure that we do everything that we can, whether that be on smoking cessation, drugs and alcohol or obesity. I mentioned asthma, for example, and the need for clean air. A lot of focus is still on the mental health preventative space as well. You will see that in the 2023-24 budget. I can give you examples of where we are spending on preventative measures. I am keen that we do not lose sight of that, even with the pressure of the current demands on the service.

We will regularly do those analyses. I do not disagree with the fundamental premise of Paul O’Kane’s question, which is that, if you pay people better, you have a better chance of recruitment and retention. We believe in that. Notwithstanding the fact that he and I completely agree on the premise of his question, we cannot take money out of the NHS, because we still need to deal with the demand pressures that we have in it. We cannot just take £1 billion out and say, “Right, we’re going to put £1 billion in here because we think that money is better spent here”. We will do that to an extent—that is the entire point of budgeting—but, at the moment, I could not justify taking the cost of £15 an hour, or even £12 an hour, initially, away from the NHS and putting it into social care.

I am keen to work with local authorities and to do what we can to continue to increase pay where we can, but it is not just about pay. I accept that pay is fundamental, but there are also issues with the terms and conditions of the social care workforce and their career progression. If there is more that we can do in that space, I am absolutely up for that. That is always part of the calculations and analysis that we do. Perhaps I should not put words in Paul O’Kane’s mouth, but I do not think that he is suggesting that we take the cost of paying £12 an hour out of the NHS just now and put it in to social care. That would have a significantly detrimental impact on the NHS at this stage.

I do not have much to add. I have been in Government for more than 10 years and we have always been encouraged to work across portfolios. I can certainly say that, in this session, the Deputy First Minister has really made sure that any hint of silo working or compartmentalisation is quickly snuffed out. We are working exceptionally collaboratively.

There are lots of examples that we can give. Emma Harper has mentioned a couple, and the Glasgow pathfinder project that is set out in the tackling child poverty delivery plan is another. I agree with the premise of your comments.

I might bring Richard in shortly, given his experience in this regard. I do not argue with Audit Scotland’s premise or the point that, I think, the deputy convener is making: multiyear budgets clearly help with planning. That is not unique to the health service; it is the case right across portfolios. That is why the spending review was an attempt to give at least a high-level overview of what budgets might be for future years. Our difficulty is the unstable economic circumstances that we find ourselves in.

You talked about sitting here a year from now. If we were to go back a year, I do not think that any of us would have expected to see inflation at the level that we currently see it at, nor, indeed, would we have expected to see some of the geopolitical factors playing out and having an impact on the economy in the UK and in Scotland in the way that they have.

There is so much that we can do around multiyear spending reviews, as we have done. They are not budgets—I accept that point—and do not go into the detail that a budget necessarily would, but they are an attempt, at a high level, to give some idea of what the financial envelope will be for future years. I entirely accept the point that that is different from a budget and that multiyear budgets could be more helpful. I think that the barriers you asked about are the instability and the economic circumstances domestically and globally.

Richard, is there anything to add from your experience?

I will take the second part of the question first. There is a genuine discussion to be had about alcohol and drug services being part of the national care service and the pros and cons of that. I can see the argument from those who oppose and have some concerns about that. We are taking time—we are doing research, working with general stakeholders and so forth—before we make any decisions about a number of services that might fall under the national care service.

As I said, the current plan is for the national care service not to be fully operational until the end of the parliamentary term. I have already given public commitments about entering into discussions with and hearing from political parties and, indeed, external stakeholders on whether they feel that that timetable is right.

Notwithstanding all that, and without putting words into my colleague Angela Constance’s mouth, whom I speak to on that issue very regularly, we have excellent ADPs across the country that do some phenomenally good work. Angela’s role is vital, because it gives us a national oversight of what is working on the ground and what is not. Of course, the lack of consistency was one of the reasons why the medication-assisted treatment standards were brought in.

You can bet your bottom dollar—this be of no surprise to the convener at all—that Angela is all over that with every single ADP and all the partners involved up and down the country. We have in place red, amber and green status, and we know who is doing well on what MAT standard and how far they are from whatever standard. Therefore, we—Angela will certainly do this—will keep a close eye on the governance and monitoring of that.

On the 2023-24 budget, part of the increase is an additional £12 million to deliver the cross-Government plan that will be published early in the new year. That speaks to the point that Emma Harper was making on that cross-Government, cross-portfolio working.

It is still a very uncertain time. Although we are in a different phase of dealing with the pandemic and are much more into the endemic phase, it is still a very challenging time, as we all know, for NHS boards up and down the country. We are trying to revert to some of the pre-pandemic processes that we had in place. For example, in this financial year, we are urging boards to get into a position of balance. It is fair to say that we do not expect every single board to quite get there, but we are making it clear that if further brokerage is required, as per the pre-pandemic arrangements, they will have to look at the repayment of any additional brokerage. We are getting back to practices that we had pre-pandemic, which help the financial stewardship of NHS boards.

As you know, there are still a number of boards—three—that have been escalated in relation to their financial performance, and we continue to work exceptionally closely with them. Given the phase of the pandemic that we are in, we are taking an even closer look. We already had quite a close relationship with those three boards, but we are taking an even closer look at what can be done to get them to de-escalate in relation to their financial performance.

If I am being frank and honest, there is still a way to go in that regard given the experience of the past two and a half years—almost three years—of this pandemic, during which the financial landscape has been so uncertain and unstable. Given that we suddenly had to fund a whole new vaccination programme and so on, I am very keen, now that we are in this new phase, that the boards are getting back to really sound financial management; I certainly get that impression from the annual and mid-term reviews that I have with the boards.

I referenced the comments from the BMA about the EBR savings that we looked to make. Obviously, we have a significant budget for 2023-24, but I have no doubt that the reprofiling that we had to make in primary care had an impact. I will not argue about that with Dr Gulhane or the BMA, but it is why our strategy, over a number of years, has been to increase those multidisciplinary team members that you talked about. We have recruited more than 3,220 since making that announcement. On top of that, there have been increases in general practitioners. We still have a way to go in that regard, but I am pleased that we were able to ensure that, in the 2023-24 budget, primary care will be well funded. That puts it on a sustainable footing.

All that having been said—I do not need to tell Sandesh Gulhane, given that he is working in primary care—the workload pressure on our GPs is still exceptional, even with the multidisciplinary teams in place. That is why I am very keen to try to ensure that that workload is spread more evenly. For example, I have spoken about NHS 24 and what more can be done around that. You will see in the 2023-24 budget a significant investment in primary care that I am proud to stand by.

I cannot put a figure on that just now. There are a number of drivers for looking at the use of digital, as well as other reforms to the NHS. One is the demand on services across the country. There is no getting away from the fact that, whether in primary or secondary care, people are presenting as sicker and with higher acuity levels. That is due to the pressure that the pandemic brought to bear and the fact that people were not able to access services, particularly at the beginning of the pandemic, as a result of the really difficult choices that we had to make to suspend or halt services such as screening.

One reason for reform and innovation is the demand that the system faces and will face in future years. The other is cost. We absolutely have to look at the fact that our health service now costs the Scottish Government £19 billion, which is a significant investment. Obviously, that investment in the health service will continue but, as others have said, simply putting more money into the health service will not necessarily help us to improve services. Although that investment will certainly help, innovation has to be key, and digital has to be part of that.

The BMA is among those calling for, as it puts it, a “national conversation” around the NHS. Whether we have a national conversation or call it something else, there is absolutely space to have a conversation with the public about how they want their health service to respond to their needs in the future and what kind of reform they want to see. I make it absolutely clear that reform should always be within the founding principles of the NHS—there should be no ifs, buts or maybes about that—but discussions about reform and innovation are crucial.

That is a good question. It is really hard to say, because it is difficult to determine the number of patients with Covid and the number who are in hospital because of Covid. Given where we are with community-wide testing, the question is probably near impossible to answer definitively.

However, we have to get to a stage—it is right that we do—where we treat Covid as we treat flu and other such viral infections. I understand people’s concerns about that, particularly the concerns of those who care for somebody who is vulnerable or those who are themselves vulnerable or immunocompromised. I completely understand the nervousness that they have been expressing from the moment we began to reduce community testing. Essentially, as Emma Harper’s questions alluded to, we do not have the funding from the UK Government to continue that testing, so we have to get to a space where we treat Covid as we treat other viral infections of that nature.