Public Audit Committee [Draft]

Meeting date: Thursday, March 21, 2024

Official Report 711KB pdf

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Section 23 Report: “NHS in Scotland 2023”

I welcome everyone back to the meeting for consideration of agenda item 3, which is on the section 23 report on the national health service in Scotland in 2023. I welcome our witnesses for this evidence session. We are joined by the Auditor General for Scotland, Stephen Boyle. Good morning, Auditor General. The audit director, Cornilius Chikwama, is back with us for this session. You are very welcome, Cornilius—good morning. Leigh Johnston, a senior manager at Audit Scotland, is also joining us, as is Martin McLauchlan, who is an audit manager at Audit Scotland.

We are a little bit up against the clock this morning, Auditor General, but, before we get to our questions, I invite you to make an opening statement.

Many thanks, convener, and good morning, committee.

I am pleased to bring you my latest annual report on the NHS in Scotland. My previous reports on the NHS have largely focused on the immediate response to the Covid-19 pandemic and then on plans to move from response to recovery. The report before you takes a longer-term view, however, and reflects the need for significant service transformation to ensure the sustainability of Scotland’s health services.

Health continues to be the single largest area of Scottish Government spending, accounting for around 40 per cent of the Scottish budget. Rising demand, operational challenges and growing costs have added to the financial pressures on the NHS and, without reform, may affect its longer-term affordability. If the situation continues unchecked, there is a risk that Scotland’s NHS will take up an ever-growing share of the Scottish budget, resulting in less money for other vital public services.

In 2022-23, health boards saw the end of Covid-19-specific funding, but some associated costs continued. At the same time, general inflationary pressures, increasing utility prices and higher-than-expected pay deal prices significantly increased NHS spending. All boards met financial break-even targets in year, but more than a third of territorial boards needed financial support from the Scottish Government to do so. Seven boards failed to deliver planned efficiency savings and, overall, the NHS remains reliant on one-off savings. Even if ambitious future savings targets are achieved, boards are likely to require further financial support.

In addition to financial pressures, operational performance continues to be challenged. Services are yet to operate in the way they did before Covid. Activity in secondary care has increased but is outpaced by growing demand. There has been some progress in reducing the longest waiting times, but key waiting time standards are not yet being met, and overall waiting lists continue to grow, with new patients being added more quickly than existing patients are being seen.

The NHS workforce is its single biggest and most important resource. Staff are reporting that they are under significant pressure and face sustained challenges. Vacancies continue to be unfilled, and staff turnover and absence rates are increasing. More bank and agency staff are being used to cover those vacancies. In particular, the costs of agency staff increased by more than 25 per cent in the financial year in question. Operational performance and workforce challenges are having an impact on patient safety and experience. Concerns have been raised in relation to overcrowding, staff wellbeing and the continuing use of bank and agency staff.

Financial and operational pressures have contributed to the NHS struggling to implement elements of its 2021 to 2026 recovery plan, including the longer-term reforms that are required. The national policy context in which the NHS operates is complex, and we set out much of that in our report.

There are a range of strategies, plans and policies in place, but there is no single overall vision for how health services will look in future. The absence of that direction is hindering boards’ ability to plan and deliver reform at the scale, pace and ambition that is required. To deliver effective reform, the Scottish Government needs to lead on the development of a clear national strategy for health and social care. It should include investment in measures that address the causes of ill health in order to reduce the longer-term growth of demand for healthcare, and it should put patients at the centre of those future services.

As ever, we will do our utmost to answer the committee’s questions.

I am going to kick off with a question that relates to the last point that you made, which was your critique that there is not really a long-term national vision for the national health service in Scotland. We have a new Cabinet Secretary for NHS Recovery, Health and Social Care in post. It is not your job to advise Government ministers what to do, but in the context of the job that you do have, what do you think the benefits would be of there being a clear national vision for the national health service? What effect would that have on the ability of boards to deliver the services that we need them to deliver?

For the record, my role clearly excludes me from commenting on the merits of policy that is in place, but we make recommendations on financial sustainability, delivering value for money and improving performance of public services. That assessment lies at the heart of today’s report. There are many policies, plans and strategies—we set out some of the timeline of the past 20 years in part 3 of our report—but there is no overarching vision.

We believe that such a vision is so necessary because of the pressure and challenge that health and social care services in Scotland are experiencing, as we set out in the report, and as many other organisations have commented on. Our assessment is that we are unlikely to see a significant departure from our current circumstances in the medium term if we do not have a longer-term vision of how Scotland’s people will remain fit and healthy for as long as possible. Investment in preventative measures, at the expense of the investment that we are making in secondary, reactive and acute settings, can move us away from what seems to be a very challenging context for the delivery of health services to one that is sustainable and affordable.

I will end on a financial note. We continue to see this in our work, which draws on the work of others, notably the Scottish Fiscal Commission. It forecasts that, without change, in the years to come, approaching 50 per cent—we are currently at 40 per cent—of the Scottish budget will be consumed by health spending, which will mean less money for other vital public services. That need and the case for reform applies not only to health and social care settings but much more widely, in my view.

Thank you for painting that bigger picture. That is a useful way to start the evidence session. I invite Graham Simpson to put to you some questions that follow on from that starting point.

I am aware of the time constraints, so I promise to be brief. Auditor General, your report provides a summary of progress by the Scottish Government against the recommendations in your 2022 report. You have made a third of the recommendations in that report again, so to what extent are you satisfied with the progress that has been made?

We think that there is more to do in setting out clearly the progress that has been made against the NHS recovery plan. That can be measured and reported. There is a clear trajectory from the actions and intentions of the recovery plan through to what was delivered.

I will pass to Leigh Johnston in a minute. It would be helpful for me to set out for the committee our assessment of a range of measures and statements, but it is quite hard to track from the recovery plan to what is actually being delivered, hence why we repeat the recommendation from last year’s report in today’s report.

10:45  

We made that recommendation last year and, again, we call for greater transparency. The progress report on the recovery plan was published this year and, yet again, it is very difficult to track the progress that is being made on some of the commitments and the ambitions that are set out in the recovery plan.

For example, there is no mention of the progress that is being made towards additional capacity. The work on the national treatment centres is being paused. That was one of the key things that was going to offer the additional capacity in the system, and there is no mention of the delays to the NTCs in the progress update to the recovery plan.

There are other areas, such as the number of people who are self-presenting to urgent care services. Again, that is not being tracked in the recovery plan. Although different things have been done to try to improve cancer care, for example, the only reference in the median waiting times is against one of the cancer waiting time standards. There is no mention in the progress update of the poor performance with regard to cancer waiting times. Therefore, yes, we think that it would help to have more transparency on the progress of the commitments and ambitions that are set out in the recovery plan.

That is very interesting. Does it come back to the committee’s recurring theme about the lack of data?

You are right, Mr Simpson. A feature of many audit reports has been the need for better data and to really plan for outcomes. An Audit Scotland report from a number of years ago said that, when publishing strategies or plans, public bodies—and absolutely the Scottish Government—should know how they intend to measure, track and then report. Therefore, there is a very clear issue here, and I refer the committee back to the evidence, and the committee’s own reporting, on adult mental health arrangements in Scotland, because there was a very strong theme in that that, although data exists in a stronger context in acute and secondary settings, there are still data gaps in primary care. Therefore, yes, there is much work to do on that.

It seems ridiculous that we want to see progress but that, as Leigh Johnston said, it is difficult to track it. That is an absurd situation. I am not asking you to respond to that; that is my view: it is absurd.

I will ask you about something else. This came up when we were questioning NHS Forth Valley health board. It has had its problems, but it broke even because it received extra money from the Government. In effect, it was bailed out. That has happened to other boards. Therefore, all the boards have broken even but some of them have had extra money. As you said, Auditor General, there is an overreliance, as we saw with Forth Valley, on non-recurring savings. Do we have a situation that is not sustainable?

I will ask Martin McLauchlan to come in to set out in more detail what we set out in the report. However, to address your question directly, yes, that is our belief. In its current guise, the system is unsustainable.

Context is everything. During the pandemic, as the committee might recall, individual boards were supported. We did not see any experience of brokerage—the term that the Scottish Government used for providing financial support. As we have come out of that period, we have got back into a cycle that we perhaps remember from before the pandemic of individual boards experiencing financial challenges and, as they move towards the year end, engaging with the Scottish Government with regard to the fact that they are not going to be able to break even, and then a range of individual tailored financial support is provided.

You mentioned Forth Valley. However, as I mentioned in my introductory remarks, five out of the 14 territorial health boards required brokerage—financial support—to break even. Mr Simpson, you also looked to the wider context, which Martin can elaborate on, of the fact that non-recurring savings remain the vehicle through which health boards deliver their financial targets. That is not about the more fundamental aspect of system change, evolution and a longer term plan but moving from one challenging financial year to another. I will bring Martin in to elaborate on that.

Good morning. It is fair to say, and the Scottish Government and individual boards accept, that the financial challenges are stark. In 2022-23 we saw a reintroduction of brokerage arrangements. The rationale for setting out the financial support arrangements that the Scottish Government has introduced is to attempt to address such challenges. Under the previous regime, historic issues around brokerage would have led to formal escalation. The situation is now at a point where escalation would perhaps not be by exception, so the support framework aims to address that.

On reliance on non-recurring savings, a 3 per cent baseline revenue resource limit recurring savings target is now in place for boards. You will see from exhibit 3 that the achievement of savings in 2022-23 proved to be difficult. Without pre-empting what will come from the current financial year, which we are almost at the end of, and the new financial plans that will be submitted, you will see from exhibit 4 that, even if the savings were made, and the forecast savings were reliant on non-recurrent measures, there was still a residual deficit that had to be addressed.

I will be brief, because I know that other members will want to come in, but I have a final question. Did your report look at general practice?

Fundamentally, no. We have not made an assessment of general practice in this audit. However, as our report mentions, it is my intention to do a wider, specific audit of primary care services in Scotland, which we will undertake in the course of 2024, with a reporting date to be confirmed.

I highlight, for the committee’s interest, that the Accounts Commission for Scotland, which oversees local government services, of which integration joint boards are part, will publish a performance and financial overview of IJBs in the coming months. However, general practitioners will be covered in my audit of primary care services.

The next questions come from Colin Beattie.

My first question is about staffing. Paragraph 25 of your report, on page 14, refers to the commitment to increase the NHS workforce by 1 per cent over the next five years, which equates to 1,800 whole-time equivalents. The NHS already has a record number of staff, although there are still many vacancies. The 1 per cent commitment does not take into account any reduction in WTE hours as the NHS comes down to a 35-hour week. Should it be reviewed in the light of those factors?

Ultimately, decisions about the size and structure of the NHS and the number of workers are policy decisions for ministers. As we note in that paragraph and the preceding one, the number of workers in the NHS—whether WTE or actual—is increasing, but although the NHS is experiencing record cash funding levels and a commitment has been made to provide extra staff, demand is also increasing. In addition, there are wider pressures on Scotland’s workforce, which we are reporting on.

If I may, I will address the point that the number of working hours will be a factor. My colleagues might want to come in on that, too. In the past few weeks, the NHS has moved from a working week of 37.5 hours to one of 37 hours, with the direction of travel being towards a 36-hour week in due course.

More widely—as the paragraph to which you referred mentions—the aim is to establish a 35-hour week, which is consistent with the fair work agenda and the public sector pay policy, which sets out the Scottish Government’s ambition to move all public bodies and their staff to a 35-hour week. That will have a bearing on finances, productivity and outputs, so the Scottish Government will have to manage significant complexity if it is to deliver that level of growth in the workforce and the changes that underpin it through working hours.

Is the 1 per cent that is referred to entirely arbitrary, or is it based on need?

Leigh Johnston might want to say more about how that will be delivered through an effective and clear workforce strategy. Our report refers to the need for such clarity and the fact that the workforce strategy, accompanied by workforce plans, gives the Government and health boards a model for making those changes.

The 1 per cent figure was set out in the “National Workforce Strategy for Health and Social Care in Scotland”, which was published in March 2022. Our report says that we are awaiting an update on progress with that strategy. As part of that, the Scottish Government has committed to publishing projections of what the future workforce will look like, based on modelling. We are still awaiting that, but we have been assured that it will be published in spring 2024.

I imagine that the 1 per cent figure might be reviewed as part of that. As I have said before, we know that the national treatment centres have been paused. Staff would have been needed for those centres, so there might be a slight reduction in the number of staff required if those are not going ahead. We will not know the answer until we see those projections and the update on progress on the national workforce strategy.

You are waiting to see the direction of travel regarding what will happen down the line with the 1 per cent, given the reduction in the working week and so on.

Yes—that is a fair assessment. There is no doubt that the circumstances are complex and involve a number of variables. Leigh Johnston mentioned the role of capital investment in the national treatment centres. There are plans to address waiting lists and there are growing costs because of staff pay deals, drugs budgets and the need to invest in the estate. A huge number of variables will have to be fed into the workforce strategy and—as I mentioned in my discussion with the convener—the wider strategy.

It is pretty much impossible to tell much from such a crude figure, because we do not know how it is made up. Not all of the increase in staff will come from nurses, but we do not know what the breakdown is. I assume that there is no breakdown.

The update to the workforce strategy, which Leigh Johnston mentioned, is central in that regard. It is welcome that that is imminent, because it should give NHS practitioners, patients and this committee some clarity. We look forward to seeing that.

Staying on the issue of staff, the increases in the use of agency and bank staff—which is a favourite topic of ours—are pretty eye-watering. In paragraph 26 of your report, you say that total agency staff costs increased by 25 per cent in 2022-23, and that there was a 79 per cent annual increase in spending on agency nurses. That figure continues to go up. Every time there is a report, we are assured that the NHS is working on that and that it will manage it down, but that does not happen. That is a huge cost to the NHS. Is there any belief that that figure might reduce in future? It is such a significant cost.

It is probably more for NHS leaders than it is for me to give you a reliable response to that question. Our intention is to highlight the fact that, as you said, the increase in the use of agency staff has been a recurring issue in health service delivery, although it was interrupted by controls and relaxations both during and after the pandemic. As I said in my introductory remarks, our report draws attention to the effect on the patient experience and on the staff whom agency staff work with, as well as to the additional cost of agency workers.

We think that it would be appropriate for the national workforce strategy to refer to and address that issue, which has recurred for many years, but NHS leaders are probably best placed to address that.

11:00  

I will move on to estate management. For a number of years, the capital budget that has been available to the NHS has been fairly generous, relative to other areas of the public sector, and there have been lots of new building projects and so forth. In paragraph 27, on page 16 of the report, you say:

“Around 70 per cent of the estate is in good condition and used efficiently.”

However, it is likely that there will be some constraints on that budget in the future, given the cuts to the capital budget. In the briefing, you recommend that the Scottish Government should

“develop and publish a national NHS capital investment strategy”

to clarify how its spending will be prioritised in the future and how the overall estate will be managed. Why do you believe that that strategy is so important? Do you know whether the Scottish Government intends to accept that recommendation?

I will tell you why I believe that it is important, and Martin McLauchlan will update you on our understanding of the Government’s position on accepting the recommendation.

I refer to the infrastructure briefing paper that we produced last year and the evidence that the committee recently took from Scottish Government officials on that matter. We deliver health services in safe settings—hospitals, general practitioner centres and health centres—across the country. You are quite right that 70 per cent of those buildings are in good condition, but, unfortunately, the arithmetic tells us that 30 per cent are not. That chimes with the fact that more than £1 billion of maintenance is required.

Government officials told the committee that the availability of capital budget means that they will have to make some very difficult choices that will have an impact on the progress of the plans for national treatment centres. There is also a sense that the Government is thinking about where to go next. In the infrastructure briefing paper, I made a recommendation on the need for a wider review of the use of Scotland’s public buildings—not only its administrative buildings, but its operational assets. I still believe that that is an important factor. Public services need to be assessed and reviewed in that way as part of the Government’s thinking around reform.

The Government’s position was that administrative buildings remain its focus currently. However, the ways in which we access health services will change in the future, so if we are genuine about moving to a preventative model and about having a national strategy that underpins that and takes us from the position of challenge that we are currently in to a more sustainable model, there needs to be a more encompassing national strategy that also looks at how the NHS and the Government plan to invest in their estate. That will mean that we can address the challenges of today and also be fit for the future.

I will pause and bring in Martin McLauchlan to talk about the interaction that we have had with the Government on that recommendation.

I will try to keep it brief. My understanding is that the Scottish Government has accepted that recommendation and is currently preparing an asset management and investment strategy.

The underlying point, as the Auditor General outlined, is that, if there is a lack of new investment and there is already a substantial backlog of maintenance, the ability to address maintenance by way of replacement is not there. When there is a pause in investment, it is very important to look at how one can manage maintenance of the estate, but, more importantly—as we alluded to in part 3 of the report, and as the Auditor General mentioned—boards need to shape and manage their estates to be fit for the future. There has to be a longer-term aspect to the planning, not only for investment and maintenance, but for the likely nature of the estate that will be required in future to deliver services.

You said that the Scottish Government has accepted the recommendation. Did it give any indication of the timescale? I realise that it is probably quite a big task.

I believe that it has asked for submissions from health boards. My understanding is that, as part of the 2024-25 budget documentation and communication with boards, it indicated that the strategy was being prepared, but I am not 100 per cent clear on the exact timescale.

Will the Government come to you once that is in place, or will it just publish its strategy?

I expect that it should be published without any liaison with us, Mr Beattie. If we have more information on that, we will come back to the committee, but it is perhaps for NHS Scotland to address that directly with the committee.

I omitted to mention that another thing to look out for over the next few weeks is the publication of the infrastructure investment plan, which will set out the Government’s priorities as they relate to individual projects, alongside the medium-term financial strategy for the next few years.

My final question is on monitoring and support. Just before paragraph 37, in the subheading on page 20, you conclude that

“There is a need for greater clarity about Scottish Government monitoring and support”.

What made you decide to make that recommendation? You sketch out a bit about it in some of the other paragraphs, but what led you to make it?

You are referring to the second recommendation, which is that the relationship between new financial engagement arrangements and the support and intervention framework should be widely understood ahead of the submission of financial plans, as Martin McLauchlan mentioned.

That goes to the heart of the financial challenges that are being experienced by NHS boards. I hope that such understanding will lead us away from the circumstances that we find ourselves in, in which NHS board funding is a rolling one-year challenge, and we can move towards a more sustainable model of clarity on investment. That builds on some of the work that was reasonably referred to in relation to the financial improvement group—the roll-out of good practice and so forth. There should be clarity on the submission of financial plans and on what is asked of individual boards.

This is a wide-ranging report, but I appreciate that we are short of time, so I will focus on specific areas, particularly the operational performance of the NHS, which affects the public more than some of the other issues.

The first obvious area to cover is where we are on waiting time targets. In that respect, the report makes grim reading. Albeit that the exhibit goes up only to September 2023, it seems to me that none of the eight key metrics on performance against waiting times is being met, and that some are failing by quite some margin—in particular, accident and emergency treatment times, the standard that cancer treatment should start within 62 days, and the 12-week in-patient and out-patient targets. What is your general view on whether things are getting slightly better or whether the long-term trend, certainly from 2018 to now, has been a trajectory of increased waiting times?

You are right: exhibit 8 sets out the challenges that the NHS is experiencing. Leigh Johnston might want to say a bit more about that in a moment. As you said in your assessment, challenges are being experienced in the round, and that reflects a five-year trend of deterioration in performance. However, the picture of performance within the past 12 months is more mixed; some indicators have improved, while some have deteriorated.

When you drew on the data, you mentioned, in addition to A and E performance, waiting times for initial cancer treatment. I would highlight that, in paragraph 46, we note that cancer in particular is a focus of the First Minister in the 2023-24 programme for government, and that the Cabinet Secretary for NHS Recovery, Health and Social Care has an objective of improving the time that cancer patients have to wait before they receive their first treatment.

Leigh Johnston might want to say a bit more about the longer-term trends.

I do not think that things are improving; they vary across different boards. I should point out that there is information on our website on the performance of different boards, and it shows that, for example, no board is currently meeting the 62-day cancer waiting time target, the target for new out-patient appointments within 12 weeks, the target for in-patient and day-case treatment within 12 weeks or the 18-week referral-to-treatment target. As we say in our report, waiting times are longer—and waiting lists are substantially longer—than they were before the pandemic. Although there has been some improvement in activity, it is still well below pre-pandemic levels.

We know the obvious effect on people’s general health of waiting for longer to be seen and for treatment to start; clearly, it will be negative. Have we done any analysis of mortality rates in that respect? I am looking specifically at the numbers of those waiting for long periods of time—that is, over a year or over 18 months—and they are stark. In 2019, around 3,500 people in Scotland were waiting more than a year for out-patient treatment, and that figure is now up to 40,000, which is a massive increase.

As for the 18-month wait target for in-patient treatment, which is presumably for those with serious conditions, the number was only 486 previously—486 too many, it has to be said—but it is now up to 17,000. My suspicion and my worry are that not all of those people will make it to their treatment. Has there been any analysis of that?

Extending our work into that analysis of mortality rates or excess deaths was not a feature of our methodology this year, although we have explored the issue, particularly in some of our reporting during Covid. Instead, our report makes a broader assessment of both the patient experience to which you are referring and patient safety in the round, drawing on the work of Healthcare Improvement Scotland and other bodies in setting out the experience that people are getting. That is not just to do with waiting times; the situation with pressures in hospitals is not where the clinical experts want it to be, either. Hence, there is work to do.

Your wider point is right, though, deputy convener. We do not have the data that you ask for to hand, unfortunately, but I am sure that the situation that you refer to would be supported by statistical analysis of the numbers and, regrettably, of what are likely to be increased mortality rates as a consequence of the longer wait times.

That is obviously very sad. We are talking about numbers, but we are also talking about people passing away while waiting for treatment. If the incidence of that is increasing, that is clearly worrying for all of the Government and the Parliament.

One issue that we discuss often and which frequently comes up is that of situations arising in accident and emergency. In your report, you cover specific issues of overcrowding in A and E, ambulances queuing outside and people not being handed over within the one-hour target. An hour is quite a long time to be sitting in the back of an ambulance anyway. Is there any evidence that that target is being substantially exceeded? As politicians, we have access to anecdotal evidence, but is there any statistical or quantitative data to support that? What is the situation in A and E across Scotland?

I will pass to Leigh Johnston shortly to update the committee on our understanding of the situation.

A and E waiting times are not being met: that is the high-level message that we should be absolutely clear on, and we have set that out to the committee. It is reasonable to recognise that the Scottish Government and NHS bodies are doing their utmost to address that, and we refer to their work and engagement with the Scottish Ambulance Service to try and improve turnaround times and the extent of the waits that people are experiencing, not just at A and E departments but also, regrettably, in ambulances queuing to get people into A and E.

The other thing that I will mention before passing to Leigh is that, as we say in the report, neither A and E nor ambulances are suitable places for people to receive longer-term care. There has to be real consideration and change if the current arrangements are not working, in order to improve throughput in A and E. Stepping back a second, however, I would suggest that the issue is how we help people not to have either planned or unplanned attendance at A and E in the first place.

I will ask Leigh Johnston to elaborate if she wishes.

11:15  

As we have said in our report, the Scottish Government issued new guidance in April 2023 to support the safe and timely handover of patients who arrive at hospital in an ambulance. That guidance states:

“By August ... 100% of patients should be handed over within 60 minutes.”

However, we know that turnaround times indicate that handover within one hour is not always achieved and that turnaround performance varies across boards.

I echo what the Auditor General said: a lot of work is going into trying to address those issues by trying to redirect people not just away from accident and emergency to the best place for them to receive care, but away from the need to call an ambulance in the first place, if there is somewhere better that they can receive care. When people arrive at hospital, how do we prioritise those who are sometimes queuing in the ambulances and ensure that most urgent cases are seen first? Lots of work is going on to reduce that pressure on unscheduled and emergency care.

It is very hard to identify which risk factor to address. I suppose that there are a number of such factors, one of which is the potential volume of people who go through the system, because it is the only option available. What work could be done to find out what percentage of those people would be immediately removed from the system if other options were available?

Another factor is the delays caused by a current shortage of staff on the ground, while a third is the throughput of people who, once they have presented to A and E, should be transferred somewhere else, but there is no somewhere else for them to go. The somewhere else is at capacity, too, so that creates a bottleneck in the system.

I presume that the answer is that all three risk factors are involved. Are there any specific areas where immediate action could be taken to alleviate the situation more quickly?

It is a combination of all those factors. As I have said, work is going on to reduce unplanned A and E attendances, where people turn up and self-present. There have been lots of different initiatives, such as flow navigation centres and clinical triage hubs, to try to make sure that people are sent elsewhere or have an appointment to attend A and E—what we call planned attendance. We know that the numbers of unplanned attendances at A and E are lower than they were before the pandemic, but we do not have data on how many people are now turning up as planned attendances.

Through other initiatives such as flow navigation, some people will turn up with a planned appointment, but we currently do not have the data that will allow us to understand how many unplanned and planned attendances there are. We know about the unplanned attendances, but we do not know about the planned ones, and Public Health Scotland is working on trying to make that data available and robust.

Perhaps I should declare an interest, convener, having gone through that process of getting a planned A and E appointment. Such appointments were news to me, but the approach seemed to work reasonably well.

In the interests of time, I will ask my final question, which is on appendix 3. I am new to the committee, but I am aware that you have produced previous reports on the NHS and made very specific recommendations to the Scottish Government. Appendix 3 contains nine key recommendations covering a wide range of areas for consideration. My analysis shows that, of the nine, five are in progress, limited progress has been made on three and no progress at all has been made on one; in other words, none of those recommendations has been completely implemented. Is that a normal state of affairs at this point? Without giving a personal opinion, are you content that the direction of travel is a good one? I am thinking in particular of the NHS recovery plan, which, although clearly important post the pandemic, has seen no progress. How have you reached that conclusion?

We are dealing with complex and sometimes intractable issues. Our recommendations are designed—and I would characterise today’s report on the same basis—to acknowledge that the system has to change and move to a more sustainable model. Our recommendations are along those lines.

Some of those recommendations are in progress, and in some, limited progress has been made. Some involve quite direct things that we think can happen now, such as transparency on progress on the recovery plan. Others, such as the 10 or so recommendations that we make in today’s report, will require action over a number of years, assuming that the Government accepts those recommendations—indeed, Martin McLauchlan has mentioned one of them—in the round.

There is some mitigation, in that the circumstances are complex. However, the convener asked about a clear national vision, and the committee might choose to take evidence on whether the Government accepts the recommendations. In the event that the Government did so, we would expect thereafter to see a clear programme and plan to implement them. However, today’s assessment, in the round, is that there has been limited progress against last year’s recommendations.

Is it inevitable that the health budget will reach 50 per cent of all Scottish Government spend? That sounds like a massive figure—perhaps one that the public is not even quite aware of sometimes. Could that be prevented?

I think that it is not inevitable and I do not believe that it should be. I am recommending today that there should be an intervention so that there is a more sustainable, affordable model.

I know that we are short of time, convener, but this point is important. The Government’s own assessment, which was undertaken with experts—it engaged with the Organisation for Economic Co-operation and Development on its approach to realistic medicine—is that around 20 per cent of spending on healthcare does not lead to improved health outcomes.

The system is the system, but that does not mean that it should be the only way in which we deliver health and social care services. It is absolutely appropriate that the Government, with the support of Public Health Scotland, looks at a three-horizons model. It has a vision and a plan to move from what is currently an unsustainable system to one that avoids the need for an ever-growing health and social care budget at the expense of other vital services.

Thank you very much. I now invite Willie Coffey to put some questions to you.

On performance, I spoke to NHS Ayrshire and Arran’s chief executive only last week about the specific 31-day target for cancer treatment. She said that the board continues to meet the 95 per cent level, and that it actually reached 100 per cent in November. I do not know whether there is a little discrepancy in the data-gathering period for your report, Auditor General, but that was what she clearly said to me last week.

I will ask Leigh Johnston to comment on that. As Leigh mentioned, we have a more detailed regional assessment—we do not set out it out in our report, but it is accessible through a link to our website. In our national reporting in exhibit 8, we cite Public Health Scotland as the source from which we draw. For completeness, exhibit 8 reports that between September 2018 and September 2023, performance dropped from 81.4 per cent to 72 per cent, where it currently sits. We can certainly check how that relates to the information that you have had from NHS Ayrshire and Arran, if Leigh Johnston does not have that detail to hand just now.

I do not have the exact data for NHS Ayrshire and Arran. The point that we make is that some boards are struggling to meet the target. Performance is just below target, as you can see, at 94.9 per cent—the target is 95 per cent. That slight reduction is because about four boards are struggling to meet the target.

I thought that I would mention that, because it was a positive side of what the chief executive described last week with regard to a range of indicators that are of interest to members.

Auditor General, I remember that your predecessors, Caroline Gardner and Bob Black, both said to the committee over several years that there was a need for service redesign and transformation. We know that demand on the NHS is going through the roof—it went through the roof during Covid, and it has not yet dissipated.

Have the recommendations for service redesign and transformation that you are urging the Government to embrace changed in any way since then? Is the model for service transformation that your predecessors envisaged the model that you are recommending now, given the huge change in demand in recent years?

I recognise the point that you make. Certainly, my predecessors made known similar recommendations and views about unsustainability of health and social care services. I fear that we are in a more acute position today than we were under previous Auditors General.

How to discharge the recommendations is ultimately a matter for NHS leaders and the Government, but there is enough evidence—accident and emergency waiting times, more general performance targets and the financial implications of not changing—to make a strong case that the model that we have is not sustainable. The Scottish Fiscal Commission estimates are reasonable, of course, with regard to policy choices, in that we will spend as much as we need to spend on health and social care services, but the opportunity costs for other parts of public service delivery will be severe.

You cover delayed discharge in the report and you talk about the NHS Greater Glasgow and Clyde model, which is called GLASFlow. Can you give the committee a wee glimpse of what that means and whether it is having an impact by reducing our problem of delayed discharge?

I will pass that question to Leigh Johnston. In paragraph 68 of the report, we set out the plans that NHS Greater Glasgow and Clyde is taking forward, along with its integration joint board partners.

The best way to describe it is as a continuous flow model. It involves having a regular schedule of patients moving from A and E to in-patient wards; planning goes on behind that, so that you have a continuous flow of patients. However, that system relies on beds being available; a continuous flow of discharges is part of that.

A number of health boards are using a similar model. It is important to point out that the NHS in Glasgow has said that the model is not a magic bullet—you need to line up all the bits—but it has created greater partnership and joint working across the hospital system. The health board has seen some benefits from that in terms of getting people out of A and E quicker, into hospital beds and then ensuring that their discharges are happening when they should.

That is what I was going to ask about. Is that model getting people out the door more quickly at the other end and back into the community or to where they are supposed to go? Is it succeeding in that regard?

I think that it is, in some wards. However, as we say in our report, delayed discharges remain stubbornly high across the NHS in Scotland.

Related to that issue, the chief executive of NHS Ayrshire and Arran said that one of the issues that affects discharge, interestingly enough, is power of attorney and families being able to grant and get that power. She said that that affects more than half of their discharge cases. Is that common throughout Scotland, and should we highlight that much more in order to encourage the public to embrace use of power of attorney?

That is such an important point: we set that out in paragraph 69 of the report. The situation was consistent in the three case-study health boards. We worked with individual boards when we were preparing the report to test our theories and progress, and to hear their experiences in order to shape our reporting. Power of attorney and complementary anticipatory care plans were among the preventative measures that the health boards said make a big difference. If somebody falls ill unexpectedly and relatives do not have power of attorney or do not know what the patient’s wishes are, there will inevitably be a delay due to consultation of and engagement with families in order to better understand what is needed. The feedback was that something that feels like a relatively small step could make a big difference.

On staffing and demand versus the ability to staff to meet demand, you mentioned clear difficulties. What more can we and the Government do to try to close that gap? We know that demand is increasing year on year, but we have difficulty in getting the right numbers of staff in health and social care to meet that demand. What are your recommendations for the Government on how it could help?

We have made a recommendation about having a clearer republished workforce strategy, which Leigh Johnston has mentioned. However, I recognise that this is a complex situation. It involves ambitions to increase the NHS workforce—finding the right people to fill vacancies—and keeping the existing members of staff safe and healthy, including in terms of their wellbeing. We have already mentioned workforce conditions this morning, and working hours will be a factor in that regard.

11:30  

There is a fundamental point about the environment that people are working in. We refer to that in our report, and the commentary that has come from NHS professional bodies since publication makes it very clear that it is a challenging, stressful and difficult environment to work in. Giving staff confidence to raise concerns or to blow the whistle is relevant.

We have set out a number of factors in today’s report. I do not want to be glib by saying that a strategy will resolve the situation. NHS leaders will need to take a multifaceted approach, in partnership with their staff, so that they can get to a sustainable model for service delivery.

Digital transformation can offer opportunities, as you also say in your report. Are there, throughout the system, blockages that e-health strategies, telehealth or any other way of embracing digital technology might help to unblock? Could those things help with queues that people face in relation to general practitioner contact or consultation services? Do you see opportunity in that and are we embracing enough of the opportunities to help us?

I am sure that Leigh Johnston, who looked at that closely during the audit, will want to say more. The adoption of technology to support transformation has been a recurring theme. Technology can give people access to services outside a hospital setting or allow for remote consultations with GPs. That is all well and good.

Before I pass over to Leigh, I note that one thing that might be of interest to the committee is that we are also looking at that outside the NHS context as part of our future audit work. We are currently undertaking an audit of digital access and exclusion, in order to explore in more detail the pace of change in adoption of technology. It is important that people are brought along at the right pace.

I will bring in Leigh to talk specifically about the NHS.

There is a range of outcomes. The Near Me service has made a real impact and is making a particular difference in providing accesss for people in remote and rural areas.

As we say in our report, boards have some choice about the innovations that they adopt. I think that we need more monitoring and reporting so that we can determine how digital innovations and programmes are being adopted and the difference that they are making. If we can show how effective they are and how they are driving efficiencies, we might be able to encourage more boards to adopt innovations in the future. We make that recommendation in our report.

Do you find that patients are receptive to using digital technology if they think that it might let them be seen or heard a little quicker? Are they quite open to that, or would they still prefer a direct face-to-face model?

It varies. Cornilius Chikwama might want to say a bit more about where we are at the moment. It is a mixed picture.

We did not look specifically at patients’ responses to digital technology, but the general picture from the work that we have done is that digital offers opportunities to respond to short-term operational challenges and, perhaps, to longer-term ones, too.

We highlight the Scottish Government’s and Convention of Scottish Local Authorities’ digital healthcare strategy, which is trying to make progress in such areas. The key risk that has been identified is the risk to capital budgets, which need enough funding to roll out digital options at scale. We highlight that risk in the auditor general’s report.

My final question is on leadership, especially at health board level. First, your report mentioned that four of the 14 territorial boards will be looking for new chief executives. Actually, the number might have gone up since the date of the report. My question is this: how much succession planning is there? The committee gets the impression that people move around from board to board. Is that too narrow a focus for recruitment to the senior positions? Have you a view on whether other parts of the public sector could be looked to?

The second part of my question is about non-executive board members. The committee has looked in some detail at the NHS Forth Valley experience, where there has been a governance review, fairly substantial recommendations have been made, people have moved on and so on. What are your views on recruitment, the standard of people who come forward for non-executive posts and whether the training that they receive is sufficient to equip them to do those important jobs? In the end, they are responsible for a huge part of public expenditure in Scotland—40 per cent, potentially rising to 50 per cent—under the devolved budget.

You are right: there is real change on executive leadership at some boards. The leadership of NHS Scotland is not unsighted on the level of change. We recognise that it is addressing that through its approach to succession planning in developing programmes to identify future leaders and supporting them to make the transition into challenging roles.

As I recall, your predecessor committee looked into the matter in detail a number of years ago. It held round-table sessions on NHS leadership, the attractiveness of posts, and identifying relevant factors. If anything, the situation is more challenging now than it was then, given the Covid pandemic and all the other factors that we have touched on this morning.

There is absolutely an onus on the NHS in Scotland to ensure that it is giving support, setting the right conditions and creating the environment for people to thrive in. I think that it recognises that, but it is clear that there is work to do, as is borne out by the arithmetic on vacancies and turnover.

I will turn briefly to non-executive roles. Good governance is absolutely fundamental in that setting and work on that is under way. The final section of our report examines the blueprint for good governance, which gives a framework for non-executives discharging their responsibilities.

We have not looked specifically at how boards identify candidates and whether they are bringing in the right people. We know that there has been turnover at NHS Forth Valley and other boards. It is probably too early to make an assessment, but the work of the public appointments team is crucial to that. Working under the direction of ministers, the team knows who it is getting and which skills it is looking for, and a full assessment process is in place. Paragraph 126 of our report makes passing reference to that. There are plans in place, including an external review of board governance, so that the Scottish Government has assurance that its sponsorship requirements are being discharged appropriately. We will keep that under close review.

Okay. Thank you very much indeed. I am sorry that there has been an air of rushing in the session. As the deputy convener remarked, your report is comprehensive and has given us a lot of evidence to consider. We will also consider whether we might want to invite more witnesses to give us their views on your findings in the annual section 23 audit of the NHS.

Auditor General, thank you very much for your evidence. I also thank Cornilius Chikwama, Leigh Johnston and Martin McLauchlan.

11:39 Meeting continued in private until 11:53.