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The Committee reports to the Finance Committee as follows—
CONTEXT
Report structure
1. This report analyses the evidence collected by the Health and Sport Committee during its scrutiny of the relevant sections of the Scottish Government’s Draft Budget for 2015-16.
2. The Committee requested evidence in writing and held two oral evidence sessions, on 28 October and 4 November 2014, with interested parties. This evidence is listed in the Annexes.
3. The report has four main sections reflecting the structure adopted by the Finance Committee to budget scrutiny: prioritisation, affordability, value for money, and budget processes.
4. The report considers the current budget proposals in the context of the issues raised in previous reports by the Committee on Scottish Government draft budgets.
Total health and wellbeing budget
Scottish Government policy approach
5. In oral evidence to the Committee, the Cabinet Secretary for Health and Wellbeing (the Cabinet Secretary) discussed the future challenges faced by the health service—
“Over the next few years, the demand for health and social care and the circumstances in which it is delivered will become radically different. NHS Scotland must work with its partners across the public and voluntary sectors to ensure that it continues to provide the high-quality health and social care services that the people of Scotland expect and deserve, thereby securing the best possible outcomes for people through the care and support that they receive”.1
6. The Committee welcomes the fact that in real terms the NHS boards have been protected from cuts.2 This is a clear acknowledgement of the importance placed on health and the Scottish Government’s commitment to delivering its Route Map 2020 Vision for Health and Social Care.
7. The Committee understands from the Cabinet Secretary that all of the Barnett consequentials resulting from health spending in England will be transferred to the health resource budget.3 The Committee welcomes this policy approach, especially in light of the increasing demands on the healthcare system.
8. However, the Committee is aware of the risk of imbalanced resource distribution in the public sector. Health and wellbeing are influenced not only by the level of health care services available but also by services and activities provided by other sectors, perhaps most obviously, local authorities, whose budgets have not been protected in the same way. This needs to be considered alongside spending on the health service due to the inter-related impact they have on the health of the population, and consequently on the Scottish healthcare budget.
Analysis against last year’s projections
9. In analysing the data provided in the 2015-16 Draft Budget, the Committee acknowledges that the figures are not fully comparable with last year’s budget, as the sport line and part of the equality budget line have been transferred to the newly created portfolio ‘Commonwealth Games, Sport, Equalities and Pensioners’ Rights’.
10. The Committee notes that the reduction of £29.6 million in resources allocated to ‘other health’ is considerably lower than the reduction that had been anticipated on the basis of last year’s draft budget, which set out a planned reduction of £116.5 million.
11. Similarly, the resources allocated to the NHS and Special Health Boards in the year 2015-16 have increased from the planned £9,619.6 million in the Draft Budget 2014-15 to the current £9,625.6 million in the 2015-16 Draft Budget. There has been an increase in the planned Food Standards Agency budget, from £10.9 million in the 2014-15 Draft Budget to £15.7 million in the 2015-16 Draft Budget. The more detailed budget figures in the 2015-16 Draft Budget also show that, compared with the planned expenditure for 2015-16 which was set out in the previous 2014-15 draft budget, the allocation for the centrally-retained element of the Integration Fund has increased (from £20m to £73.5m). Nursing education and training has increased by £1.3m; eHealth has increased by £2m and Care Inspectorate funding is up by £0.2m. A New Medicines Fund of £40m has been introduced. There have been reductions compared to previous plans for Health Improvement and Health Inequalities (down £8.8m); Alcohol Misuse (down £0.2m) and Miscellaneous Other Services (down £4m).
12. The health and wellbeing capital budget decreased by 28% between 2013-14 and 2014-15. This year the capital budget is forecast to reduce further by 24% in real terms between the 2014-15 budget and the 2015-16 Draft Budget.
13. The Cabinet Secretary stated that a “further £32 million has been added to the previously published capital budget to support the continued investment in NHS Scotland infrastructure”.4
14. With this additional resource, the capital reduction in cash terms from 2014-15 to 2015-16 is lower than had previously been anticipated.
15. The Draft Budget indicates that new facilities will be delivered through the NPD financing model. Due to pressures on the capital budget, the Scottish Government is using revenue (NPD) financing to support capital investment. With this financing approach, the upfront capital investment is undertaken by the private sector, with repayment and maintenance costs met through unitary charges paid from the Scottish Government’s resources budget over a period of time (usually 25-30 years).5 However, no information was provided in the Draft Budget on the repayments that the NHS boards are incurring via the NPD model and the previous PFI and PPP models. The Scottish Government provided data showing that the £122 million investment in 2014-15 will increase to £380 million in 2015-16, representing a cash increase of £258 million or 211.5%. The Committee would like to see detailed data on the ongoing unitary charges resulting from NPD and PFI projects and for this information to be presented to allow comparisons to be drawn against charges that are incurred as a result of traditional public sector capital funding for 2015-16 and in future Draft Budget documents.
16. The Committee is concerned about the possible impact that reductions in the capital budget might have on backlog maintenance. While recent evidence reassured the Committee that NHS boards were targeting the backlog, there is still concern that a considerable proportion of the backlog is classified as high risk6.
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Presentation of budget information
17. A recurring theme in the Committee’s budget reports to date has been the need for further information to be included in the main budget document. While the health and wellbeing budget absorbs 32.4% of the total resources available to the Scottish Government, the level of detail provided in the current Draft Budget document does not reflect the size of this budget allocation.
18. The Committee also notes other chapters in the Draft Budget are likely to be of relevance to the ‘Health and Wellbeing’ chapter. It would be helpful if the Scottish Government highlighted these inter-relations in the Draft Budget document and its analysis, particularly in light of the integration of health and social care. It would also be useful if the Scottish Government could clarify the money that has been transferred in or out of the health and wellbeing budget from other portfolio areas.
19. The Committee reiterates the requests it made in its budget report last year for more detailed information to be contained in the main budget document or provided as supplementary information, including—
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the data provided by the Scottish Government in response to the Committee’s request for further information in its Draft Budget Report 2013-14 (which included retrospective and anticipated cost pressures such as pay, prescribing, equal pay claims etc.) to be a dedicated appendix or supplementary document;9
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the provision of a comprehensive publication that will allow the lay reader to gain a better understanding of the data; 10
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more insights into the way health inequality is being tackled; 11
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more insight into the links between the performance measures and the overall aims of the healthcare system; 12
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more indication on the performance the Scottish Government plans to achieve and how this can be linked with outcomes or output indicators; 13
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further information on performance indicators; 14
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information on impact assessments so the Committee would be better able to assess efficiency;15
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a clear statement of capital investment plans, including the financing method and the capital/revenue implications of major projects, along with the revenue impact for the coming years;16 and
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more information on the distribution of need and inequalities in the Scottish regions, with an indication of resources dedicated to tackle emerging problems.17
PRIORITISATION
Determining priorities
20. When taking decisions and investing resources, it is important to understand the areas of action that need to be prioritised. This is a particularly essential assessment in times of financial constraint.
21. At a time when financial resources available to the public sector are expected to decrease, the Committee recognises the need to assess future spending requirements and plan future actions accordingly.
22. These are issues explored in Audit Scotland’s report NHS in Scotland 2013-14 which comments on the performance and future plans of the NHS. The report highlighted the shift from hospital care to social care provision—
“Progress has been slow and more significant change is needed to move more care into the community. The NHS will not be able to continue to provide services in the way it currently does. Change on this scale will be challenging at the same time as NHS boards are expected to meet demanding targets for hospital care and when budgets are tightening.”18
23. The Committee explored with witnesses the issue of prioritisation within the health budget.
24. Dr Andrew Walker told the Committee that, whilst there was cross-party consensus on many aspects of health policy, consideration needed to be given as to which of the priority areas were most important. He told the Committee—
“What there is not a consensus on is on priorities. Everyone agrees that integration is a good thing. Everyone agrees that public health and prevention are good things. Everyone agrees that more access to new medicines is a good thing. However, what do you do when you cannot have all those three things? Which one of those is the most important across parties? That is the part of the debate that is still missing. Everybody quite likes hospitals, but everybody quite likes primary care as well. When you cannot have both, which do you choose? I am still waiting for that debate to happen in Scotland.”19
25. In oral evidence to the Committee, the Cabinet Secretary explained the key priority areas contained in the Route Map to deliver the Scottish Government’s 2020 Vision for Health and Social Care—
“The route map describes 12 priority areas for action in three domains: first, improving the quality of the care that we provide; secondly, improving the health of the population; and thirdly, securing the value and financial sustainability of the health and care services that we provide. I believe that those three aims must be central, and are central, to our funding commitments, which are contained in the 2015-16 draft budget.”20
26. The Committee agrees with the comments made by the Cabinet Secretary on the key priority areas for action on health and social care. Taking action in these areas will be essential to the future of our health service and meeting the objective of ensuring that everyone is able to live a longer and healthier life.
Targets
27. As highlighted in previous Committee budget reports, there is a large number of performance measures and frameworks used by the Scottish Government in relation to health. These measures and frameworks include the National Performance Framework (NPF), the Quality Measurement Framework, Healthcare Quality Strategy for NHS Scotland, Better Health, Better Care, the 2020 Vision Route Map, HEAT Targets and a range of indicators/measures used for local improvement and performance management, including core sets of specific indicators for national programmes, such as clinical indicators.21
28. Jill Vickerman of BMA Scotland suggested that there was a lack of linkage between the budget and the Scottish Government’s performance measures and frameworks—
“The budget document does not have a joined-up narrative with regard to how the various different lines of investment that it describes will come together to deliver the Scottish Government’s aspirations.”22
29. Dr Andrew Walker told the Committee that the number of performance frameworks and measures can make it difficult for an observer to understand their relevance and how they relate to each other.23
30. The Committee notes that the National Performance Framework (NPF) underpins the delivery of the Scottish Government’s agenda and aims to present an outcome-based approach to performance. BMA Scotland commented on the relationship between the NPF and HEAT targets—
“The NPF includes a single high-level, public health target that requires the co- ordinated approach of a range of government and public sector bodies. It is difficult to measure in the short to medium term. Most managers and staff working in the NHS are more familiar with HEAT targets and the associated outcomes, strategic objectives, indicators etc.”24
31. The Committee notes that the Cabinet Secretary’s evidence focused mainly on NHS Scotland’s performance targets (the HEAT targets) and would wish further information on how the other performance measures identified by the Scottish Government are used in relation to the health portfolio.25
32. Inclusion Scotland suggested in its written submission that, whilst the Public Bodies (Joint Working) (Scotland) Act 2014 established a new set of principles and national outcomes for health and social care, it was not yet clear how these sat alongside the existing NPF outcomes, the NHS Quality Strategy or the 2020 Vision.26
33. The Committee considers it is important that the Scottish Government’s targets remain relevant and user-friendly. The various targets should also work in tandem with each other towards delivering the desired policy outcomes. It should also be possible to see how particular targets are linked to individual budget lines.
34. The Committee heard some concerns raised by BMA Scotland that the process of meeting targets can have unintended consequences. In written evidence, BMA Scotland commented that—
“Increasingly the culture of performance management has led to an imbalance between management and clinical judgment, a diversion of resources in order to achieve targets at the expense of other greater areas of patient benefit and need.”27
35. The Committee asks the Scottish Government for its view on these concerns and what assessment it conducts on the impact of meeting targets. The Committee believes it is important that the meeting of targets does not have the unintended consequences of distracting those delivering services from their roles.
36. The issue of the impact of annual targets on financial planning was explored in the recent Audit Scotland report NHS in Scotland 2013-14. The report stated—
“Strong focus on meeting annual targets makes it harder to carry out longer-term financial planning. This focus makes it difficult for NHS boards to fund services to meet current needs, at the same time as making the investment required to reshape care in line with the 2020 Vision.”28
37. A potential approach to addressing the issues raised by Audit Scotland was noted in evidence by Dr Andrew Walker, who suggested that performance measures should be considered in two groups: those that change slowly and can be assessed over a longer time frame (for example, over five years); and the indicators that require more regular monitoring to make sure that corrective actions are taken to deliver the desired results.29
38. Dr Andrew Walker further suggested that differentiating between the two groupings would allow attention to be focused on the more important actions, while the other indicators would be assessed but over a longer period of time.30
39. The Committee asks the Scottish Government for its view on the merits of dividing the performance priorities and targets into two groups: ones to be monitored on an annual (or more regular) basis, and ones that present long-term milestones.
40. The Committee also notes that, in addition to HEAT targets a number of HEAT standards are set for each year. Standards are targets that boards have achieved, but to which they must continue to adhere. The Committee asks the Scottish Government for further information on how it monitors performance against HEAT standards by NHS boards.
Outcomes
41. Some witnesses suggested that there should be greater transparency in how the Scottish Government assesses the potential impact of spending before taking decisions on prioritising particular budget lines. Dr Andrew Walker told the Committee—
“Another decade long problem is the lack of any link between planned spending and planned outputs or outcomes and this stifles debate about the allocation.”31
42. Jill Vickerman of BMA Scotland expressed a similar view on the need for there to be a clear evidence base as to why particular decisions on the budget were being taken—
“There is currently no clarity on how we make decisions on how much to invest and how we prioritise different areas.”32
43. Professor David Bell suggested there was a need to assess the rationale behind budget decisions. He noted that decision-making could be informed by a better understanding of the financial impact of alternative options for investment – for example, whether an investment in childcare would deliver a larger increase in income tax revenues than an alternative investment in mental health services.33
44. The Draft Budget 2015-16 increases the Integration Fund to £173.5 million: £100 million to integrated partnerships via NHS Boards and a further £73.5 million to be held centrally by the Scottish Government to support national initiatives.34 On 4 November 2014 the Scottish Government announced additional funding of £40 million for GP and primary care services to be drawn from the £73.5 million Integration Fund.35 The Scottish Government also announced, on 20 November 2014, additional funding of £15 million over the next three years for mental health services. The 2015-16 funding for mental health services (£5m) will also be drawn from the £73.5 million Integration Fund.36
45. The Committee welcomes the announcement of additional funding for GP, primary care and mental health services. In light of comments regarding the need to assess the rationale behind budget decisions, the Committee calls for the Scottish Government to provide further commentary on the reason for this increase in spending allocation, specifically how the decision to increase funding in these areas was assessed against the potential benefits of increasing the financing of other services.
46. The Committee also notes the likely demands on the Integration Fund during the 2015-16 financial year as the provisions of the Public Bodies (Joint Working) (Scotland) Act 2014 come into force. The Committee asks the Scottish Government to provide further information on how it will prioritise spending within the Integration Fund and for a full breakdown on the allocation of the £73.5 million. Finally, the Committee seeks reassurance from the Scottish Government that the total funding available within the Integration Fund is sufficiently large to meet the likely demands during 2015-16, particularly in the light of some of the available funding being diverted for other purposes.
47. The Committee also explored the rationale for prioritising specific budget lines including the New Medicines Fund and the Family Nurse Partnership.
New Medicines Fund
48. The Committee welcomes the introduction of a dedicated budget line for the New Medicines Fund (NMF) and the comments made by the Cabinet Secretary that ensuring appropriate care and treatment for people who require specialist and often expensive medicines for rare conditions remains a priority.37
49. The Committee notes that the investment of £40 million in the NMF is a doubling of the commitment made by the Scottish Government last year.38
50. Dr Andrew Walker told the Committee that he felt it was not clear how the £40 million figure for the NMF had been arrived at. The Committee notes that during its own consideration of the issue of access to new medicines, different figures were suggested as being an appropriate level of investment in the fund.
51. In evidence to the Committee, the Cabinet Secretary explained that investment in the NMF had initially been committed for two years as the funding from the Pharmaceutical Price Regulation Scheme (PPRS) was a new source of revenue and the overall budget from the UK Government beyond 2016-17 was not yet known. He also told the Committee that he believed, in principle, that there was a need for a more permanent NMF.39
52. Dr Andrew Walker questioned how the Scottish Government would deal with a situation where more medicines were added to the fund in the future, which would drive up cost40—
“In 2015 we can imagine there will be enough new medicines qualifying that the £40 million is used up – but unless the status of those medicines changes, there will be the same £40 million cost in 2016-17, plus more new medicines arriving in that year that will also need to go into the fund – so – seemingly – it will require £80 million of funding.”41
53. Access to new medicines has been a key area of focus for the Committee’s work in recent years. The Committee asks the Scottish Government for further information on how it identified the final budget figure for the NMF and how future funding will be determined. The Committee will scrutinise this funding stream closely, to assess the extent to which the level of demand for the fund increases over the coming financial years and how the funding is spent. The Committee believes that the Scottish Government should be ready to respond, given the likelihood of increasing demand emerging as more medicines are approved for use in NHS Scotland.
Family Nurse Partnership
54. During the Committee’s recent scrutiny of NHS board budgets, the majority of boards indicated that it was not possible to measure savings resulting from preventative spending, particularly at this early stage.42
55. One example of preventative spending is the Family Nurse Partnership (FNP). The 2015-16 Draft Budget includes an additional £4.4 million to support the continued expansion of the FNP programme, with a focus on supporting parents in deprived communities.
56. Professor David Bell told the Committee that, whilst investment in the FNP might represent good value for money in the long term, there was a degree of uncertainty as to whether it would represent the best value for money out of all the possible spending choices. He explained that there was a lack of methodology to assess which of the spending choices delivered best value for money.43
57. The Committee has previously taken evidence on FNP and remains supportive of FNP. However, the Committee recognises the challenges faced in justifying investment in preventative spending when the positive outcomes and financial savings may not be realised for many years. The Committee therefore asks the Scottish Government to clarify how it plans to monitor the effectiveness of FNP and how the lessons from this type of preventative spending might influence future spending decisions. In particular, the Committee would ask the Scottish Government to provide information about any short to medium term indicators that it intends to use to measure progress being achieved through FNP.
AFFORDABILITY
Challenges
58. It is widely acknowledged that the demands on the NHS are increasing. As Audit Scotland’s NHS in Scotland 2013-14 report details, the NHS in Scotland is facing significant pressures particularly from the growing population of elderly and very elderly people; the number of people with long-term health conditions; and people’s rising expectation of healthcare. The NHS is having to make major changes to services to meet future needs.44
59. The Audit Scotland report also states that longer-term forecasts to 2018-19 by the Office for Budget Responsibility show a real-terms reduction in total UK public sector expenditure of 0.7 per cent in both 2016-17 and 2017-18, before levels are maintained in 2018-19. The NHS in Scotland 2013-14 report notes that reductions in spending at a UK level will affect the level of funding available in Scotland. The Scottish Government will need to plan for health spending within an overall reducing budget.45
60. The Committee also notes the points made in the draft NHS boards’ Chief Executive paper dated 6 August 2014, which was the subject of a leak to the media and widely reported in September. The paper was produced as an internal management paper. It lists a series of challenges facing NHS boards, including the anticipated change in funding and cost base, constraints on capital funding, workforce requirements and demographic changes. 46
61. Jill Vickerman of BMA Scotland told the Committee that there were “significant and worrying pressures across the health system”47 which had “come together in a perfect storm”.48
Integration agenda
62. The Committee in its previous budget reports acknowledged the challenge faced in efforts to modernise care provision, particularly at the community level, through the integration agenda.
63. This challenge remains and, during this year’s budget process, stakeholders reiterated calls for a radical change in the healthcare system to deliver this agenda.
64. The Committee received comments from several witnesses suggesting that marginal changes to the health budget would not be enough to sustain the delivery of healthcare services. Instead the Draft Budget should do more to provide the “boost”49 “acceleration”50 or “levers”51 to create change. Some witnesses argued that this change would require additional resources.
65. BMA Scotland raised concerns that the current focus on processes and structures as part of the integration of healthcare and social care services in the short term could distract from the long-term challenge of improving and reorganising the services.52
66. The differing funding profiles of the local government and health portfolios were highlighted as posing a challenge to the delivery of the integration agenda.
67. The Royal College of Nursing Scotland stated—
“It is not always clear that these government work streams are well integrated in their plans for the future of health care and moves to redesign services, nor always realistic in their desire to effect change with little, if any, additional resource. Too often approaches are rooted in existing ways of working, rather than offering truly creative thinking on how to build sustainable team-based services. And often we do not see them taking account of the powers that will be placed in the hands of integration authorities from April 2015 to radically redesign pathways of care and disinvest in existing services and buildings.”53
68. The establishment of partnerships is a key driver for the Scottish Government’s integration plans. However it is not possible to identify the resources allocated to these activities from the budget documentation. The Committee requests further information from the Scottish Government on how the health boards, which are the largest recipients of the Integration Fund, will use the resources to achieve the outcomes required to deliver the integration agenda. The Committee is keen to receive further information on how the Scottish Government will monitor the progress of the integration programme.
Delayed discharges from hospitals
69. The Committee was pleased to hear from the Cabinet Secretary that the so-called ‘step up step down’ arrangements, where healthcare and social care services work together to speed up the transfer of people no longer needing acute care, have been successful in some areas.54
70. However, the Committee notes the data in the Audit Scotland report that in 2013/14 “only three boards met the delayed discharges target (NHS Ayrshire and Arran, NHS Orkney and NHS Shetland)”.55 Usually a failure to meet the four week discharge delay target is due to the lack of a place in a care home. If the delayed discharge is under two weeks, this is usually due to delayed community care assessments.56
71. The Cabinet Secretary also revealed in evidence that he “recognised the need for the living wage throughout the social care sector” and spoke of the challenge that low pay presents for the sector in relation to recruitment and retention.57 The Committee would like to understand further how the Scottish Government would plan to address these issues, given that many staff are not directly employed by either the Scottish Government or local authorities.
72. The Audit Scotland report also revealed that around 25% of patients in acute hospitals do not have clinical reasons for remaining there, but are obliged to do so because there is no suitable care home place available or arrangements for their support in their own home and community have not yet been put in place.58 Clearly, given the costs of keeping people in hospital compared to supporting them in their own home or keeping them in a care home, a 25% inappropriate occupancy rate of hospital beds does not represent a good use of NHS resources, particularly at a time when it is important to maximise the efficiency of the service.
73. However, the Audit Scotland report highlights that—
“The Scottish Government is working with boards over the next year to help them manage beds better in the short term, including developing a bed- planning toolkit. […] The toolkit will be piloted in 2015 and include scenario planning based on assumptions of demand, admission rates and length of stay, taking into account demographic patterns and more care being provided in the community.”59
74. The Committee notes and welcomes the work being undertaken by the Scottish Government and boards to develop a bed management toolkit. The Committee invites the Scottish Government to provide more detailed information on how this toolkit will work in practice, in due course.
Specific pressure on the budget
75. The Committee has identified a number of particular areas in which there are pressures on the health budget. These are considered in turn in the following paragraphs.
Workforce planning
76. BMA Scotland told the Committee that it was aware of various workforce planning pressures, including examples of high vacancy rates for consultants in health boards, pressures on the staffing of GP out-of-hours services and accident and emergency units, and difficulties in filling partner posts in general practice.
60 BMA Scotland also voiced concerns that doctors were being required to work increasingly longer hours whilst their salaries were declining in real terms. 61
77. Rachel Cackett of the RCN Scotland called for “creative ways” to deal with workforce planning issues.62
78. The Cabinet Secretary highlighted to the Committee that there have been changes in the profile of the NHS workforce (for example the increasing number of women in the workforce) with greater demand for part-time working.63 The ageing population and changing working patterns have implications for the future NHS workforce. Some changes are to be welcomed such as the higher levels of female employment in the NHS.
79. Another issue explored with the Scottish Government was the provision of the living wage to all directly employed NHS Scotland staff in comparison to the situation in England. In supplementary information provided by the Cabinet Secretary he clarified—
“In Scotland, we have, for the last two years, chosen to be more generous to the lower paid within the NHS generally than has been the case in England, meaning that those earning below £21,000 are in appreciably better position in Scotland. […]
The lowest paid in particular are doing better in Scotland because we have applied the Scottish Living Wage by discounting the lowest pay point on the Agenda for Change pay matrix.”64
80. The Committee welcomes the commitment to pay the living wage and the recent 1% pay award for NHS staff, which will impact most on the lowest paid staff within the NHS. However, the Committee notes that these commitments, together with the increased employer contribution to pension schemes, will impact on the resource levels available to boards in the future. The Committee may wish to consider some of these issues in more detail during its annual budget scrutiny of NHS boards’ budgets, but in the meantime asks the Scottish Government to provide further information on the impact of these changes on the resources of NHS boards.
81. These challenges are not new, but there is a lack of evidence in the draft budget to demonstrate how they will affect service delivery and how spending patterns will change as a result. Assurances need to be provided that there is an appropriate allocation of resources by the Scottish Government and health boards to meet these current and future challenges. There remains a lack of quantitative evidence on how these issues are being addressed to make such an assessment. As mentioned above, this is an issue that the Committee is likely to return to in its budget scrutiny of NHS boards.
Health inflation
82. The Audit Scotland NHS in Scotland 2013-14 report highlights that healthcare inflation in the UK is higher than general inflation, which has an impact on the health budget in real terms. The Audit Scotland report states that, over the last 20 years, general inflation in the UK averaged just over two per cent a year while health service costs rose by 3.6 per cent a year.65
83. The Committee notes that information provided by the Scottish Government to the Committee shows that NHS board budget uplifts have been in excess of the Hospital and Community Health Services (HCHS) pay and price inflation index.66 The Committee is keen to determine the impact health inflation has on the provision of health services and was disappointed to learn that this information is not produced for Scotland. The Committee notes that an annual inflation series which includes data on health inflation and GDP deflators is published for Hospital and Community Health Services in England. The Committee believes that the provision of equivalent data in respect of Scotland would increase transparency and aid scrutiny, and invites the Scottish Government to consider the feasibility of providing such data in support of future draft budgets.
NRAC formula
84. As noted in Audit Scotland’s NHS in Scotland 2013-14 report, some of the challenges experienced by health boards, including NHS Orkney and NHS Grampian, are exacerbated by the fact that the revenue allocation is or had not been aligned with the expected NRAC formula.67
85. The Committee notes that the Scottish Government has the objective that all NHS boards should be within 1% of NRAC parity by 2016-17. The Committee asks the Scottish Government to provide further information on how resources will be identified to meet this objective and the impact that this transfer of resources will have on other priorities and services.
VALUE FOR MONEY (VFM)
86. Value for money (VfM) is difficult to assess in any meaningful way at this stage given the lack of detail on planned Board spending. Moreover, in some cases, there are difficulties in making an assessment on VFM, as some data – for example, data on Allied Health Professionals services at national level – are not regularly collected.
87. This section of the report, however, summarises some elements related to VfM that emerged from the Committee’s budget scrutiny process.
Benchmarking
88. The Committee would be interested to learn how the Scottish Government uses any comparative evidence to assess the performance of NHS boards. The Committee would also be interested to learn if and how this information is fed back to boards and the extent to which it influences budget allocation, if indeed it does at all.
Private sector
89. The Committee explored with the Cabinet Secretary the provision of private services in the NHS. The Cabinet Secretary told the Committee that spending on the private sector accounts for 0.9% of the total health budget. He told the Committee that the Scottish Government did not use the private sector to replace existing capacity in the NHS, but instead to buy in capacity that did not exist in the health service—
“There are some diagnostic tests that are done in the private sector because we do not have the specialism required to do them, and from time to time there is provision for treatment in the private sector because we do not have the capacity to provide it in the national health services. That is very different from privatising national health service facilities, procedures and operations.”68
90. The Committee notes that there is some private sector spend through agency staff, which are more expensive than NHS employees (for example, a locum doctor costs 180% of the cost of an equivalent NHS doctor or GP69). The Committee would be interested in the Scottish Government’s management of its agency staff budget, how its likely level is estimated and what action the Scottish Government takes to contain it. It would also be useful to have this information extracted from the board staffing costs. As indicated by the Cabinet Secretary and specified by his official, “the information on private sector spend relates to the use of services and hospital facilities; it does not include nurse agency and medical agency spend”. This information has subsequently been provided to the Committee, but it would be helpful for the Committee to get this information on a regular basis.70
91. The Committee would welcome a breakdown of the private sector spend according to the type of service being purchased. It would also invite the Scottish Government to set out clearly the rationale for use of private sector services. In particular, the Committee would like to gain a better understanding of when it is considered appropriate to access services externally rather than develop expertise within the NHS.
Capital
92. The Draft Budget states that in the coming year the NPD programme will support capital investment in the health sector of £380 million. While the Committee welcomes the information that capital resources continue to be invested in the healthcare sector, it would ask for more detailed information alongside future draft budgets on funded projects, the rationale for investing in these projects, the expected benefits and the value for money that the NPD programme will have in the short and long-term.
93. Quantitative data currently made available are not sufficiently detailed to make a judgement of the rationale of particular investments and the consequent ‘value for money’. The Committee considers that, in the interests of proper scrutiny, it, the Parliament and the wider Scottish public should have access to more detailed information.
94. Data should also be made available to allow independent and critical assessment, which would stimulate discussion and possible choices, highlighting how benefits and costs have been assessed, as highlighted to the Committee by Dr Andrew Walker and Professor David Bell. More open disclosure of data and criteria used would allow more critical assessment of the benefits of specific approaches and identification of alternative ones to take place.
Public health
95. The Committee notes the suggestion by Dr Andrew Walker that part of the savings originating from efficiency savings, rather than being retained by the NHS board could be transferred to the public health services. This would encourage a more innovative approach in the service and avoid the risk that the resource retained in the NHS board would simply continue funding services on a historical basis.71The Committee would welcome comments from the Scottish Government on Dr Andrew Walker’s suggestion.
BUDGET PROCESSES
96. The Committee received a number of general comments on the budget process. Dr Andrew Walker, for example, told the Committee—
“As the Committee has noted in the past, the draft budget is only a statement of the allocation; there is no attempt to provide data on anticipated cost pressures.”72
97. The Committee also received suggestions of a disconnect between the objectives that the Scottish Government is pursuing, as highlighted in the first part of the Health and Wellbeing chapter, with the budget lines provided in the second part of the document. Inclusion Scotland, for example, in its written submission, argued that there was “no clear linkage between the budget as currently formulated and the policies, principles and outcomes set out” in the Public Bodies (Joint Working) (Scotland) Act 2014. It concluded that it was “clear that future budgets will need to be reshaped to more clearly identify what funds are being allocated [to health and social care integration] to enable proper scrutiny and assessment.” 73
98. Other submissions to the Committee also reflected some concerns over the future development of joint working under the Act. The RCN Scotland said that it was “unclear how fully integrated health and social care budgets will be scrutinised by parliamentary committees within the budget cycle in future years.”74 Similarly, Inclusion Scotland argued that—
“The integration of health and social care is at risk of being undermined as funding for the NHS is operated differently from that of social care. Unless the way these systems are funded is brought into line (which would necessitate a review of social care funding) integration could result in cost creep in the NHS. It could lead to administrative barriers to integration resulting from efforts to disentangle the systems.”75
99. Kim Hartley of AHPFS also told the Committee that she was “concerned that, wherever the money has gone”, it did not “seem to be working to bring about integrated and fully multidisciplinary planning at either central or local level”. She added that she thought that, “centrally, we could start to demonstrate the integrated behaviour that we would like but which we are not getting at the moment and to enable local agencies to make some smart decisions on the basis of real evidence and real data”. 76
100. As Annie Gunner Logan of the Coalition of Care and Support Providers in Scotland suggested77 it is arguable that the way in which the budget is constructed does not seem to assist in promoting the structural and cultural changes that are widely agreed to be required if primary care, social care and other public services are to be reconfigured and reshaped in the ways set out in the Public Bodies (Joint Working) (Scotland) Act 2014.
101. Moreover, the budget document still lacks any clear linkage between priorities and spend. Taking into account the comments made by Dr Andrew Walker and Professor David Bell it would be interesting to understand how much of the healthcare budget is prepared using a traditional “incremental” approach, and what elements are assessed on a more “zero-based” approach. While the Committee appreciates that many elements of the budget associate with largely fixed costs and realistically, therefore, can only be built on an incremental basis there may be assets or services where a reassessment of their value would be useful. The Committee suggests that there may be a case for more of a zero-based approach in relation to budget setting, particularly in relation to integrated boards. While recognising that the detailed budgetary decisions for these boards will be taken by existing NHS boards and local authorities, the Committee invites the Scottish Government to consider how to develop the budget process in a way that reflects the new structural arrangements, perhaps with a budget line dedicated to integrated working.
102. More detailed information on the spending in particular areas such as tobacco and alcohol would also be useful, along with a board level perspective. As requested by the Committee in previous years, in order to carry out an effective assessment of the budget, it would also be helpful to have information on the varying levels of inequality in the different boards and areas of Scotland and the related resources allocated and actions taken by the boards to tackle their specific health inequality issues.
103. The Committee accepts that the use of resources allocated to NHS boards by the Scottish Government is, ultimately, a matter for the boards themselves and not one that can be determined centrally through the annual budget process. That is why the Committee has developed its budget scrutiny approach to encompass more direct scrutiny of NHS board budgets. Nevertheless, the Committee would invite the Scottish Government to consider whether there is scope, through the budget process, to demonstrate more explicitly the links between budget lines and targets and objectives.
104. The difficulty in getting a picture of total spending in a particular area was highlighted by the Cabinet Secretary in evidence to the Committee:
“There is a danger in assuming that a particular headline budget line is the totality of money; it is not. As Dr Simpson knows, there are many other aspects of the health budget, including those in the territorial boards’ budgets, in which work is going on that does not necessarily feed into budget lines, as we do not put things in twice—obviously, we put them in only once. We have to look at the total picture.”78
105. The Committee notes its intention to undertake further scrutiny of the Board budgets once details are available. However, it also notes the challenges in undertaking any assessment of a total picture of spending in particular areas and would welcome any information that the Scottish Government can provide in this respect.
SPORT
106. In its budget approach paper, the Committee agreed to focus primarily on the health and wellbeing portfolio. The Committee plans to dedicate further consideration to the sport and physical activity elements of the budget in the future.
107. The Committee wrote to the Cabinet Secretary for Commonwealth Games, Sport, Equalities and Pensioners’ Rights to seek further information on the sport and physical activity elements of the 2015-16 Draft Budget. The response received from the Cabinet Secretary is listed in Annexe C to this report.
108. The Committee notes that the First Minister announced to the Chamber on 6 November 2014 a £25 million underspend on the delivery of the Commonwealth Games.[79] Media reports indicate that the Scottish Government intends that the first £6 million of the saving will be spent on the establishment of a new national para-sports centre, £2 million on the legacy programme and the remaining revenues to be allocated to the health service.80
109. The Committee assumes that £25 million underspend on the Commonwealth Games will be allocated as part of the 2014-15 Spring Budget Revision. The Committee asks the Finance Committee to scrutinise this amended spending plan for the Budget (Scotland) Act 2014.
110. The Committee asks the Scottish Government for further information on how the underspend will be spent within the health budget. The Committee notes that the draft budget allocates £6 million to the new national para-sports centre. The Committee seeks clarification from the Scottish Government on whether the First Minister’s reference to £6 million of the Commonwealth Games underspend being spent on the national para-sports centre is additional money to the allocation in the Draft Budget.
EQUALITIES AND CLIMATE CHANGE
111. The Committee agreed to include consideration of the impact of budget decisions on equality groups (at the request of the Equal Opportunities Committee) and to adopt a similar mainstreaming approach with climate change (as requested by the Rural Affairs, Climate Change and Environment Committee).
112. The Committee believes that, in future years, subject committees should also be encouraged to mainstream health inequality impacts within budget scrutiny. The Committee’s continuing inquiry into health inequalities highlights the cross-cutting nature of the problem and the Committee would like to suggest that an input is sought from other Committees on budgetary aspects in their portfolios as they relate to health and wealth inequalities.
113. The Committee notes that the Equal Opportunities Committee’s specific emphasis this year with regard to budget scrutiny is on age. This is an issue discussed in this report within the context of the challenges and specific pressures demographic changes are placing on the provision of health and social care services.
114. The Committee’s call for written views on the draft budget included a question on the impact of the health budget on climate change policy. NHS Health Scotland stated in its written response to this question that “the impact of health spending on climate change is difficult to determine”.81
115. NHS Health Scotland explained that this was because the majority of greenhouse gas emissions arise from indirect emissions and it was difficult to measure these wider impacts. In contrast, direct emissions were easier to determine and formed part of the HEAT reporting of NHS boards.82
116. NHS Health Scotland noted that there was debate about how to minimise the greenhouse gas impact of health services. It can be argued that efficiencies derived from technological advances would not be likely to reduce greenhouse gas emissions because the resources would be reinvested in other forms of consumption such that the net impact would be unchanged. 83
117. The need to reduce energy consumption was raised by the Scottish Ambulance Service in its written response. It told the Committee that, as part of its efficiency and productivity programme, it was looking at the issue both in terms of fuel economy and in terms of incorporating energy saving measures into the design of its buildings.84
118. The Scottish Government Health and Social Care Directorate’s written response provided an oversight of the total carbon emissions attributed to the 2015-16 Health and Wellbeing Draft Budget. It stated that emissions amounted to 2.3 megatonnes of CO2-equivalent. This represented 26% of the estimated emissions attributed to the Draft Budget as a whole and broadly reflected the size of the portfolio budget.85
119. The Scottish Government explained that with an average of every £1 million of expenditure in Health and Wellbeing generating 0.2 Kilotonnes of CO2- equivalent, it was one of the least carbon intensive portfolio areas.86
120. In oral evidence to the Committee, the Cabinet Secretary for Health and Wellbeing said that the total energy bill for the NHS was in the order of £70 million a year. He explained that the estate strategy was to seek to improve energy consumption, including using renewable energy resources and district heating systems.87
121. The Committee recognises that with 26% of the estimated carbon emissions attributed to the Health and Wellbeing portfolio in the Draft Budget, the portfolio has a key role to play in the delivery of what are widely acknowledged as ambitious climate change targets. However, as the Committee has stated in previous years’ budget reports, it considers that more information could be presented within the current budget documents to demonstrate how measures in the Draft Budget can contribute to meeting climate change targets.
122. The Committee notes the points raised by NHS Health Scotland on the challenges in measuring indirect carbon emissions in health spending and the debate regarding whether technological advances result in reduced energy consumption. The Committee will return to these issues as part of its scrutiny of NHS boards’ budgets in 2015.
OVERALL CONCLUSIONS
123. From the evidence, there is a clear expectation among stakeholders of the need for change in the NHS in Scotland, and a recognition of some of the stresses and tensions that are being experienced at the present time. While, as was noted in the evidence session, the NHS has managed to survive all previous predictions of ‘collapse’, stakeholders highlight that the current situation is a little different, with raised levels of dissatisfaction amongst some personnel, for example GPs, and difficulties in staff recruitment in some geographical and skill areas.
124. Witnesses recognised that it is a particular time we are living in, where the NHS and the wider care landscape need to be restructured in order to meet future demand and to make the most efficient possible use of available resources. While it is clear that the Scottish Government is fully committed to the integration agenda, the Committee’s budget scrutiny, and previous work that is has carried out over the session on the integration of health and social care, including the passage of the Public Bodies (Joint Working) (Scotland) Bill, points to a conclusion that more needs to be done, to guarantee overall cultural change and the introduction of new processes rather than simply incremental changes that would largely retain the existing structure with minimal adjustments. In this respect, as mentioned in the previous section of the report, the Committee would be interested to learn the extent to which any aspects of the budget are subject to any kind of “zero-based” approach.
125. The Committee has explored a variety of cost pressures during the course of its budget scrutiny, including for example the living wage, pay increments, general UK Government austerity measures, access to new medicines, recruitment and retention of medical staff and rising health and social care needs. The Committee welcomes the on-going protection of the revenue budget to territorial health boards, which continue to receive real terms funding increases.
126. The Committee also acknowledges the need for a debate on the impact of health inflation – which historically differs from general inflation – on the provision of health services and on the management of financial resources within the NHS. In this regard, the Committee would welcome more detailed information on the assumptions underlying the budgetary decisions and how the budget allocation links more directly into addressing cost pressures. This would also enable the Committee to better scrutinise how health boards use the budgets allocated to them by the Scottish Government.
127. As stated earlier in the report the Committee also notes that an annual inflation series which includes data on health inflation and GDP deflators is published for Hospital and Community Health Services in England. The Committee believes that the provision of equivalent data in respect of Scotland would increase transparency and aid scrutiny, and invites the Scottish Government to consider the feasibility of providing such data in support of future draft budgets.
128. The Committee’s scrutiny of the draft budget has identified, as it did last year, some recurrent issues that have been summarised at the start of the document. A major issue of concern is the affordability of some decisions made by the Scottish Government – that have not been fully justified in their rationale and impact assessment. There is limited information on the quantitative analysis used to inform investment decisions, which hampers any assessment of value for money.
129. The Committee has welcomed resources for new initiatives such as £4.4 million for the Family Nurse Partnership and £40 million increase in funding for GP and primary care services. However, as part of its on-going scrutiny of NHS expenditure the Committee would seek further information as to why resources were allocated to these priorities as opposed to potential alternatives.
130. Whilst the Committee agrees with the priorities for the NHS as outlined within the Route Map 2020 Vision for Health and Social Care, it also heard evidence questioning the role and number of targets. The Committee would welcome on-going dialogue with the Cabinet Secretary on how the Scottish Government determines targets.
131. The Committee notes that we are, as previously mentioned, at a time when changes need to take place and there is a clear perception amongst stakeholders that it is a moment for engagement of all parties, including the public. There is a need to debate, and thereafter to set out, the changes that need to be made in the health and care sectors. The Committee would expect the changes to place a higher emphasis on primary and community care.
132. The Committee also notes that, while there are widely held perceptions that the joint working agenda is bringing about change in the correct direction, there are fears that the resources to be dedicated to it may be insufficient for the fundamental reconfiguration of the system that is needed. The risk is that the acute sector is not going to be sufficiently challenged to reconfigure the way it organises and provides its services, with the result that the hoped for degree of integration and reorganisation of service is not fully realised.
133. It is acknowledged by the Committee that work to progress the integration agenda is being taken forward on a number of fronts, and that many of the detailed changes will take place at board and local authority level. Nevertheless, it might have been expected that such significant structural change might have been more strongly reflected within the budget process.
134. Over the course of this parliamentary session the Committee has demonstrated its commitment to the integration agenda. This budget year is going to be crucial in the development of that agenda and it is clear that, under the new arrangements, budget scrutiny and following the public pound is likely to become more challenging. The Committee will continue to work in partnership with Scottish Government officials and NHS boards through the boards’ budget scrutiny process, to attempt to bring further clarity and transparency to the budgetary processes that will underpin the new arrangements.
ANNEXE A: EXTRACT FROM MINUTES OF THE HEALTH AND SPORT COMMITTEE
20th Meeting, 2014 (Session 4)
Tuesday 17 June 2014
1. Decision on taking business in private: The Committee agreed to take item 5 in private and to consider the Committee's approach to scrutiny of the Scottish Government's draft budget 2015-16 and its report to the Finance Committee in private at future meetings.
5. Draft Budget Scrutiny 2015-16: The Committee considered and agreed its approach to the scrutiny of the Scottish Government's Draft Budget 2015-16.
27th Meeting, 2014 (Session 4)
Tuesday 28 October 2014
Draft Budget Scrutiny 2015-16: The Committee took evidence on the Scottish Government's Draft Budget 2015-16 from—
Dr Andrew Walker, University of Glasgow;
Professor David Bell, University of Stirling;
Rachel Cackett, Policy Adviser, Royal College of Nursing Scotland;
Jill Vickerman, Scottish Secretary, British Medical Association (Scotland);
Annie Gunner Logan, Director, Coalition of Care and Support Providers in Scotland;
Lillian Macer, Scottish Convener, UNISON;
Ms Kim Hartley, Representative, Allied Health Professions Federation Scotland.
28th Meeting, 2014 (Session 4)
Tuesday 4 November 2014
1. Decision on taking business in private: The Committee agreed to take items 3 and 4 in private.
2. Draft Budget Scrutiny 2015-16: The Committee took evidence on the Scottish Government's Draft Budget 2015-16 from—
Alex Neil, Cabinet Secretary for Health and Well-being, and Christine McLaughlin, Deputy Director: Finance Health and Wellbeing, Scottish Government.
3. Draft Budget Scrutiny 2015-16: The Committee considered evidence taken to date on the Scottish Government's Draft Budget 2015-16.
31st Meeting, 2014 (Session 4)
Tuesday 25 November 2014
Draft Budget Scrutiny 2015-16 (in private): The Committee considered a draft report on the Scottish Government's Draft Budget 2015-16. Various changes were agreed to, and the Committee agreed to consider a revised draft, in private, at its meeting on 2 December.
32nd Meeting, 2014 (Session 4)
Tuesday 2 December 2014
Draft Budget Scrutiny 2015-16 (in private): The Committee considered a draft report on the Scottish Government's Draft Budget 2015-16. Various changes were agreed to, and the Committee agreed to consider a revised draft, in private, at its meeting on 9 December.
33rd Meeting, 2014 (Session 4)
Tuesday 9 December 2014
Draft Budget Scrutiny 2015-16 (in private): The Committee considered and agreed a draft report to the Finance Committee on the Scottish Government's Draft Budget 2015-16.
ANNEXE B: ORAL EVIDNECE AND ASSOCIATED WRITEN EVIDENCE
27th Meeting, 2014 (Session 4) Tuesday 28 October 2014
Written Evidence
Allied Health Professions Federation Scotland
British Medical Association (Scotland)
Dr Andrew Walker
Royal College of Nursing Scotland
Oral Evidence
28th Meeting, 2014 (Session 4) Tuesday 4 November 2014
Written Evidence
Scottish Government Health and Social Care Directorates
Oral Evidence
Supplementary Written Evidence
Cabinet Secretary for Health and Wellbeing
ANNEXE C: LIST OF OTHER WRITEN EVIDENCE
Association of the British Pharmaceutical Industry Scotland
Community Pharmacy Scotland
Company Chemist’s Association
Health and Social Care Alliance Scotland
Inclusion Scotland
Macmillan Cancer Support
NHS Borders
NHS Health Scotland
North Ayrshire Council
Scottish Ambulance Service
Scottish Council for Voluntary Organisations
South Lanarkshire Council
Supplementary Written Evidence
Cabinet Secretary for Commonwealth Games, Sport, Equalities and Pensioners’ Rights
Any links to external websites in this report were working correctly at the time of publication. However, the Scottish Parliament cannot accept responsibility for content on external websites.
Footnootes:
1Scottish Parliament Health and Sport Committee. Official Report, 4 November 2014, Col 2.
2 The budget for the NHS territorial boards has increased by 1.1% in real terms between 2014-15 and 2015-16. This compares with a real terms increase of 1.0% in the total Scottish Government DEL budget.
3 Scottish Parliament Health and Sport Committee. Official Report, 4 November 2014, Col 3.
4 Scottish Parliament Health and Sport Committee. Official Report, 4 November 2014, Col 4.
5 Scottish Parliament Information Centre. (2014) Draft Budget 2015-16: Health and Sport. SPICe Briefing 14/72. Available at: http://www.scottish.parliament.uk/ResearchBriefingsAndFactsheets/S4/SB_14-72.pdf
6 Audit Scotland. (2014), NHS in Scotland 2013/14. page 19. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
7 Scottish Parliament Information Centre. (2014) Draft Budget 2015-16: Health and Sport. SPICe Briefing 14/72. Available at: http://www.scottish.parliament.uk/ResearchBriefingsAndFactsheets/S4/SB_14-72.pdf
8 Scottish Parliament Information Centre. (2014) Draft Budget 2015-16: Health and Sport. SPICe Briefing 14/72. Available at: http://www.scottish.parliament.uk/ResearchBriefingsAndFactsheets/S4/SB_14-72.pdf
9 A full list of the information requested is contained in Scottish Parliament Health and Sport Committee report on Draft Budget 2014-15 Paragraph 31.
10 Scottish Parliament Health and Sport Committee report on Draft Budget 2014-15 Paragraph 20.
11 Scottish Parliament Health and Sport Committee report on Draft Budget 2014-15 Paragraph 21.
12 Scottish Parliament Health and Sport Committee report on Draft Budget 2014-15 Paragraph 34.
13 Scottish Parliament Health and Sport Committee report on Draft Budget 2014-15 Paragraph 35.
14 Scottish Parliament Health and Sport Committee report on Draft Budget 2014-15 Paragraph 35.
15 Scottish Parliament Health and Sport Committee report on Draft Budget 2014-15 Paragraph 38.
16 Scottish Parliament Health and Sport Committee report on Draft Budget 2014-15 Paragraph 78.
17 Scottish Parliament Health and Sport Committee report on Draft Budget 2014-15 Paragraph 116.
18 Audit Scotland. (2014), NHS in Scotland 2013/14. page 5. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
19 Scottish Parliament Health and Sport Committee. Official Report, 28 October 2014, Col 14.
20 Scottish Parliament Health and Sport Committee. Official Report, 4 November 2014, Col 2.
21 Further information on the range of Scottish Government priorities and targets is provided in Scottish Parliament Information Centre. (2014) Draft Budget 2015-16: Health and Sport. SPICe Briefing 14/72. Available at: http://www.scottish.parliament.uk/ResearchBriefingsAndFactsheets/S4/SB_14-72.pdf
22 Scottish Parliament Health and Sport Committee. Official Report, 28 October 2014, Col 34.
23 Scottish Parliament Health and Sport Committee. Official Report, 28 October 2014, Col 11.
24 BMA Scotland. Written submission.
25 Scottish Parliament Health and Sport Committee. Official Report, 28 October 2014, Col 31.
26 Inclusion Scotland. Written submission.
27 BMA Scotland. Written submission.
28Audit Scotland. (2014), NHS in Scotland 2013/14. page 6. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
29 Scottish Parliament Health and Sport Committee. Official Report, 28 October 2014, Col 21.
30 Scottish Parliament Health and Sport Committee. Official Report, 28 October 2014, Col 21.
31 Dr Andrew Walker. Written submission.
32 Scottish Parliament Health and Sport Committee. Official Report, 28 October 2014, Col 34.
33 Scottish Parliament Health and Sport Committee. Official Report, 28 October 2014, Col 4.
34 Scottish Government (2014) Scottish Budget Draft Budget 2015-16
35 Scottish Government (2014) GP and primary care to benefit from cash boost. Available at: http://news.scotland.gov.uk/News/GP-and-primary-care-to-benefit-from-cash-boost-11e6.aspx
36 Letter to Convener Health and Sport Committee from Minister for Public Health, 20 November 2014.
37 Scottish Parliament Health and Sport Committee. Official Report, 4 November 2014, Col 3.
38 Scottish Parliament Health and Sport Committee. Official Report, 4 November 2014, Col 3.
39 Scottish Parliament Health and Sport Committee. Official Report, 4 November 2014, Col 30.
40Scottish Parliament Health and Sport Committee. Official Report 28 October 2014, Col 6.
41 Dr Andrew Walker. Written submission.
42 Scottish Parliament. Health and Sport Committee, 9th Report, 2014 NHS Boards Budget Report Paragraph 60.
43 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014, Col 8.
44 Audit Scotland. (2014), NHS in Scotland 2013/14. Page 5. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
45 Audit Scotland. (2014), NHS in Scotland 2013/14. Page 32. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
46 Chief Executive Meeting – 6 August Single Narrative Paper – revised
47 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014, Col 25.
48 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014, Col 27.
49 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014 Col 40.
50 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014 Col 40.
51 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014 Col 30.
52 BMA Scotland. Written submission.
53 RCN Scotland. Written submission.
54 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014 Col 22.
55 Audit Scotland. (2014), NHS in Scotland 2013/14. Page 21-22. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
56 Audit Scotland. (2014), NHS in Scotland 2013/14. Page 25. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
57 Scottish Parliament Health and Sport Committee. Official Report 4 November 2014 Col 41.
58 Audit Scotland. (2014), NHS in Scotland 2013/14. Page 25. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
59 Audit Scotland. (2014), NHS in Scotland 2013/14. Page 44. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
60 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014 Col 27.
61 BMA Scotland. Written submission.
62Scottish Parliament Health and Sport Committee. Official Report 28 October 2014 Col 28.
63 Scottish Parliament Health and Sport Committee. Official Report 4 November 2014 Col 9.
64 Letter from Cabinet Secretary for Health and Wellbeing 12 November 2014.
65 Audit Scotland. (2014), NHS in Scotland 2013/14. Page 31. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
66 Scottish Government. Supplementary written submission.
67 Audit Scotland. (2014), NHS in Scotland 2013/14. Page 16. Available at: http://www.audit-scotland.gov.uk/docs/health/2014/nr_141030_nhs_finances.pdf
68 Scottish Parliament Health and Sport Committee. Official Report 4 November 2014 Col 11.
69 Scottish Parliament Health and Sport Committee. Official Report 4 November 2014 Col 11.
70 Scottish Parliament Health and Sport Committee. Official Report 4 November 2014 Col 13.
71 Dr Andrew Walker. Written submission.
72 Dr Andrew Walker. Written submission.
73 Inclusion Scotland. Written submission.
74 RCN Scotland. Written submission.
75 Inclusion Scotland. Written submission.
76 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014 Col 39.
77 Scottish Parliament Health and Sport Committee. Official Report 28 October 2014.
78 Scottish Parliament Health and Sport Committee. Official Report 4 November 2014 Col 17.
79 Scottish Parliament, Official Report 6 November 2014 Col 10.
80 Scottish Government. Commonwealth Games under budget by £25 million http://www.youtube.com/watch?v=srgyxROuk5I
81 NHS Health Scotland. Written submission.
82 NHS Health Scotland. Written submission.
83 NHS Health Scotland. Written submission.
84 Scottish Ambulance Service. Written submission.
85 Scottish Government Health and Social Care Directorate. Written submission.
86 Scottish Government Health and Social Care Directorate. Written submission.
87 Scottish Parliament Health and Sport Committee. Official Report 4 November 2014 Col 43.
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