Seòmar agus comataidhean

Gillian Mackay points to what I think is the greatest risk that we have in the coming year, not just in health and social care services but across the public sector, and that is the impact that the rise in national insurance contributions will have.

We do not yet have clarity or certainty about what that impact will look like. We know that, across the entirety of the public sector, including people who are contracted to deliver public services, such as GPs, social care providers, dentists and people in the community and voluntary sectors, the cost to Scotland will be approximately £750 million. We have had an indication from the UK Government that it will cover somewhere between £290 million and £350 million, which means that we will have an immediate substantial deficit of £400 million or more.

The funding that has been suggested thus far by the UK Government is only for those who are directly contracted in our public services; it does not cover people such as GPs and social care providers and people in the community and voluntary sectors, universities and so on. We face a substantial risk. We know from social care providers, including some GPs that I have spoken to, that the rise represents an existential risk for some of them.

The UK Government has rightly sought to raise revenue, but I do not believe that it understood the implication of choosing to raise that revenue from employer national insurance contributions. That is evidenced by the fact that we still do not have clarity in terms of what it describes as the mitigations relating to the damage that the move will cause. It could have chosen other ways of raising the revenue that is required to start to unpick austerity. It made the wrong choice, and that will have potentially catastrophic implications for not just health and social care services but public services in Scotland and across the UK. That is why I hope that committee colleagues will unite with the Scottish Government in saying that the issue must be quickly resolved at source by the UK Government, so that we can provide certainty to those employers—our GPs, social care providers and so on—that are seeking to make employment decisions right now but have no certainty about what their national insurance position is going to be.

Some of those providers will be disproportionately impacted because of the nature of the route that has been chosen by the UK Government, such as those with a higher number of staff who are paid at a lower salary rate.

One of the other issues that I believe is going to be problematic is that those who are contracted to provide more than 50 per cent of their business within the public sector will not be eligible for some of the relief that the UK Government has proposed. That, again, serves to illustrate to me that the move has not been properly thought through and that the UK Government has chosen the wrong area from which to raise revenue.

Again, I underline that the UK Government should raise revenue to invest in public services to start to undo the damage that austerity has done. The revenue that has been provided to the Scottish Government through the budget is very welcome—it starts to make progress. It does not answer all the questions from the Scottish Government or, indeed, other Governments. I genuinely believe that the UK Government went down the wrong route on raising revenue and that there will be clear and stark unintended consequences that it will have to resolve—and quickly.

Yes, I absolutely recognise that, but my point is that, when someone does not need an appointment, it is difficult to understand whether they would have needed an appointment in the first place.

Our preventative activity is about reducing the overall level of interaction with secondary care services, in particular. We want to reduce the level of acute admissions and to stop the escalation of people’s ill health. All that is wrapped into what we are seeking to do in the budget, especially with the £200 million that we have set aside for reducing waiting times, addressing the efficiency of flow in the system and reducing delayed discharge. That involves providing capacity to our social care providers and our primary care providers.

The issue is not only about general practice. We have a huge opportunity with ophthalmology in the community and from encouraging greater utilisation of our pharmacy first programme. A range of interventions are available. However, I again point to the fact that not all prevention will be achieved through health service intervention. Mr Whittle and other members have spoken about the importance of our sporting and leisure facilities, as well as that of cultural and other public service interventions.

Part of the discussion that we will be having with IJBs is about the deployment of the £100 million for improving the delayed discharges picture and ensuring that IJBs have the resource and certainty available to them to allow investment in care packages and care home support.

Mr FitzPatrick asked what my expectation would be. The reduction in the levels of reserves that Alan Gray has just narrated meets the fact that there is pressure across the public sector. I do not think that anyone would expect there to be high levels of reserves sitting there when there is fiscal pressure across public services. Those things need to be balanced. I acknowledge Audit Scotland’s report in that respect, and the Auditor General’s concern about ensuring that there is financial sustainability going forward.

We must continue to work with our partners in local government and health boards to ensure that there is funding sustainability for our IJBs so that they can continue to meet service demand and be sustainable over time. We need to ensure that that is a smooth process. Alan Gray talked about ensuring that the allocated reserves are there to allow investment over time and allow some of those multiyear projects to be delivered.

Sandesh Gulhane is right that there is an oral health inequality, but it has reduced substantially. I hope that Alan Gray has access to the figures. Child oral health inequality has reduced substantially. We have seen a reduction in the number of children who arrive at dental services with cavities, so the childsmile programme has clearly made an impact and reduced inequalities.

The reason why we have invested in general dental services and reform of the funding for NHS dentistry is to ensure that our dentists find carrying out NHS work more attractive. That is also why, in the budget, we are investing in increasing the number of dental training places so that we can increase the number of dentists coming into the system. We are increasing the number of Scotland-domiciled dental places by 10 because we recognise that it is an incredibly competitive environment for potential students to go into and we want to ensure that we maximise the number of dentists who come into the health service.

I am happy to provide greater detail on the reduction of childhood dental health inequality in the follow-up correspondence. The information gives a good summary of the progress that has been made and the impact that childsmile has made. I think that Mr Gulhane will welcome that.

Yes, they were taken to address all those things. I thank Emma Harper for her reflection on the investment that we are making in predominantly rural and island boards. The national resource allocation committee formula recognises the increased challenges and costs that are associated with delivering services in those areas. Ensuring that the funding allocation for every board in Scotland is within 0.6 per cent of the NRAC formula ensures that there is parity across all boards and that boards that have challenges in delivering services, predominantly in rural and island settings, are able to deliver them. The discussions that I have had with board chairs and chief executives show that there is enthusiasm about what they can do with the increased funding and what they can deliver.

I have clear priorities on expanding primary care and general practice, in particular, and on reducing delayed discharge and waiting times. Those are clear areas of investment in the budget, because I recognise that that is what people need to see from health and social care services in the coming year. We have put our money towards our priorities.

Yes, I am happy to provide that in writing. That budget line is used to ensure that flexibility is available across the year. I cannot remember the exact reason why there has been a reduction, but the overall position for the health boards that we fund is clearly up.

Perhaps Alan Gray can provide more detail.

Yes, that is still where we seek to go. From a cash perspective, we have provided an increase to mental health spending. As Mr Sweeney outlined, there are two areas: the direct spending that is provided by Government and the service provision that is provided by our boards. We are confident that the investment that we are providing via our boards, as well as from Government, will ensure that we meet the needs of the people of Scotland.

Of course, there is a significant area of challenge, particularly after Covid, in people who present with increased and more acute mental health issues. That has been particularly stark in child and adolescent mental health services; however, particularly in those services, there has been a good story to tell for Government and boards, in that there has been a significant reduction in waiting times, and significant investment. Funding has doubled and there has been a near 50 per cent increase in staffing over the period, which has resulted in greater capacity.

Issues still exist in regional areas, and we are working with them to ensure that they meet the wider Scottish standard. The most recently reported figures on child and adolescent mental health services are the best on record and have provided a significant improvement on where we have been, which is a good news story.

We have issues with consultant psychiatric staffing. In those areas, we are working with NHS Education for Scotland in an attempt to provide the required capacity for acute in-patient support as well as support for general practices to provide mental health support from our community mental health practitioners.

There is a range of intervention in the mental health space, because we recognise that it is a growing challenge. That is borne out from the most recent census data, which demonstrates the challenge that people feel with their mental health.

That is a very good question. That is done by negotiation and discussion and by recognising where demand will be. By the way, the £2.2 billion that is coming from my portfolio is an increase of £160 million—I think—that will go into social care. That is taking us beyond the commitment that we made previously to increase social care spending by 25 per cent over the course of this parliamentary session. We have gone beyond that by £350 million. The allocation comes through discussion, predominantly between the finance secretary, who also has responsibility for local government, and me. As I and Alan Gray have set out, there is an increased baselining of local government funding to include social care spending. I am happy to provide greater clarity on that in a follow-up letter.

That is a challenge. We need to ensure that we fairly remunerate our incredible staff and that we incentivise people to choose careers in health and social care even when some of their skills could be deployed in other parts of the public sector or the economy.

I am very proud of the fact that we have provided pay deals—not just this year but in previous years—that mean that, for the majority, our health and social care staff are the best paid in the UK. We have made sure that our consultants are paid competitively compared to consultants in other parts of the UK, and we have matched UK pay review body recommendations for many, including our general practitioners.

Ms Mackay is right that balancing that to ensure that we deliver service sustainability is an important consideration. However, we need staff, including front-line staff, to be able to deliver against the clear objectives that I have set out in relation to the budget. Those objectives are: to reduce delayed discharge, which means increasing social care capacity; to increase the accessibility of primary care and general practice; and to reduce waiting times. We will need to buy greater provision, which means greater investment in staff. There is always a balancing act to be done. That is why we have set out clear support to our boards around the 15-box grid that I referred to in order to achieve recurring financial savings and service improvement to maximise the capacity of clinicians and staff and so that the productivity and efficiency of the system are sound.

The utilisation of innovation to free up clinical time and the advent of the theatre utilisation tool, which is delivering 20 per cent increased efficiency in our theatres, represent more examples of how we can ensure that every penny and every pound that we invest in the health service go further. That helps to ensure that the investments that we are making in our staff, which I am proud to make, can continue and can be sustainably achieved in the future.