Seòmar agus comataidhean

It is an operational issue, so I would expect it to be dealt with by boards. They have a whole executive team, so if there was an issue around safe staffing in a particular ward, I would expect that to be escalated through the board’s local management structure—eventually, I presume, to the director of nursing and, if necessary, to the chief executive.

If a wider systemic problem was being experienced and it was brought to our attention, we would certainly want to raise that with the board. In terms of day-to-day operations, it would be the responsibility of the individual board to deal with the matter. However, if there was a wider systemic issue, I would certainly be concerned about that and I would want to take action if there was a problem in a board.

Eventually, it will be a self-funding model, but the proposed arrangement will operate for the initial couple of years, in order to get the regulatory process up and running. As the workforce expands, it will be a self-funding model, which is the way in which most of the regulators now operate. The proposed arrangement is part of the initial process to support the GMC in taking on the regulatory role.

At present, PAs are unregulated. In Scotland, we have a very small cohort of around 150 of them operating in the NHS. Back in 2016, we issued direction around the type of role and the scope of role that could be held by a PA in NHS Scotland, so that is already defined. As the GMC takes on the regulatory function, it will be responsible for setting out the relevant definitions and the terms of those definitions.

I disagree with that, and it would be unfair to suggest that waiting times for CAMHS have not been reduced. There has been a very significant reduction in waiting times for CAMHS, and in particular of the build-up that developed over the course of the pandemic. Staff across our child and adolescent mental health services are working really hard to address the waits, and we have seen very significant reductions in them. Of course, where there continue to be extended waits, that is not acceptable, and that is why work is still being undertaken to address the issue.

However, anyone who looks at the course of the mental health budget over the past couple of years cannot avoid seeing that the budget has, in some cases, more than doubled. That has allowed for a significant expansion of services and an increase in capacity of those services, which we are now seeing the benefits of in terms of the waiting-time reductions that we are achieving in CAMHS services overall.

I recognise that challenges remain in delivery of mental health services. Notwithstanding that, very good progress is being made, and the sustained increase in investment that we have made over the past couple of years is making a difference.

Let us look at where we are with A and E at present. We have seen an improvement this year compared with where we were last year. We are continuing to work with health boards to sustain further improvements.

You will be aware that one of the major challenges that we have with A and E performance is flow from A and E into hospitals. A significant part of that is caused by delayed discharge. Despite the fact that around 98 per cent of all discharges from hospital take place on time, the 2 per cent that do not have a significant impact on flow into hospitals from our A and E departments. This year, we saw a reduction in the number of delayed discharges compared with where we were last year. I want to ensure that we do intense work this year on what more we can do to reduce delayed discharge, because we know that that is critical in supporting the flow into our hospitals.

We are doing a second element of work on reducing the level of demand at our A and E departments. For example, the work that the Scottish Ambulance Service is doing through its integrated clinical hub is reducing the number of people who have to be conveyed to our A and E departments, and that is as a result of the investment that we are making into that service.

We are doing work to improve those things, but demand is significant. I believe that we can still make further progress, and I am determined to ensure that we do that during the next year. We will continue to focus on the areas that we know will improve the performance that we get in our A and E departments and across our unscheduled healthcare system. We are making progress, but there is certainly much more to do, and there is determination to ensure that we do it.

We have, I think, five health boards at stage 3 of the escalation process. It is important to emphasise that providing tailored support to boards that are experiencing specific financial pressures is not new. The mechanism has been in place and has been used at various points over the years. Clearly, though, we are in a very challenging financial environment, so we have boards that are under extra pressure.

I will get Richard McCallum to say a bit more on a couple of areas that he has just touched on. One area is how boards manage their staffing. There is the use of agency staff versus bank staff and the issue of recruiting staff. The second area is prescribing. There are marked variations among boards in prescribing and in the costs associated with it. Although we might procure a lot of the drugs in Scotland centrally, prescribing variations can have an impact. The chief pharmaceutical officer is doing work to ensure that we do as much as we can to get greater consistency in prescribing, because that can also address issues around the costs associated with prescribing.

Richard, do you want to say a bit more on some of the other work that we are taking forward to give support around financial sustainability?

There was a consultation exercise, part of which was about which regulatory body would be most appropriate for the regulation of PAs and AAs. A significant majority of respondents—just under 60 per cent, if I recall correctly—to the consultation said that the GMC would be the most appropriate body to carry out that regulatory function. The order, and the approach that both the Scottish and UK Governments have taken, reflects the feedback from that consultation exercise.

We gave a commitment to increase investment to some £250 million during the parliamentary session to tackle the twin challenges of drug and alcohol misuse, and we are on track to deliver that and sustain that level of investment.

We are keen to see further growth in the provision of rehabilitation services, and work has been done to achieve that. The commitment that we made to ensure that there was sustained investment in drug and alcohol services is being taken forward in this budget so that we continue to see the progress that we need in the delivery of those services to improve outcomes for those who suffer from drug and alcohol misuse.

Funding for the drugs policy has increased by 67 per cent since 2014-15. There has been a sustained period of increased investment. We committed to ensuring that there was additional investment of £250 million to support our drugs and alcohol mission, and the budget builds on delivering that.

We have allocated an extra £31 million in the budget to ensure that all boards are within 0.6 per cent of NRAC parity. The largest chunk of that goes to NHS Lothian and NHS Fife.

The review group is called the technical advisory group on resource allocation. It has met three times so far, and it is drawing together work to take forward the review of NRAC. I should say that it will not be a quick process. It will take a lot of detailed work to take forward any funding formula changes or developments. The group has already started commissioning the data and information that it requires in order to look at how it could adapt the existing NRAC formula. Richard McCallum might be able to say a bit more on how it is progressing.

I will bring in Richard McCallum to talk about our work with boards on how we can share learning.

We have a formal process for monitoring all our boards’ performance, not just in terms of key targets but around financial management. We also conduct an annual review process for each of our boards to evaluate the progress that they are making; they have an in-year review as well.

One challenge that has been around for a long time—I recall this from when I was previously a junior health minister—is trying to make sure that, where there is good practice in one part of the country, it is replicated in other parts of the country. That challenge is not peculiar to health; it is a challenge within the public sector overall. It is always a source of frustration to me that, in a country of 5 million people, we struggle at times to make sure that good practice is replicated and that where it is established, it sticks.

We have a number of different mechanisms through which we seek to do that. One is that we regularly bring our board chief executives together to focus on particular areas of challenge and, where they have taken new approaches, to share that practice. We do the exact same thing with the NHS chairs of the boards. I meet them every six weeks or so; we have the opportunity to focus on key areas where there is good practice or on areas where there are challenges, in order to try to encourage good practice.

We are also making much greater use of the centre for sustainable delivery, which is based at the Golden Jubilee National Hospital special NHS board. The centre was established to look at key areas where there are opportunities for efficiencies and improvement in service delivery. It takes that forward with individual boards and it can model what the impact would be on an individual board if it were to deliver something differently. It can also do specific work with individual boards.

Over the next couple of years, the centre will probably be the key mechanism that we will use to try to get greater consistency, to make sure that we are getting better adoption of good practice where it has been identified, and to bring new ideas to boards.

I will ask Richard McCallum to say more about what we do on finance with the boards.

We are taking forward a range of work to encourage the adoption of good practice where it has been established in one board.