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Our social care staff are critical in supporting and sustaining our health and social care systems, which are interlinked and are key to each other. The social care setting has traditionally been undervalued, which has been reflected in the rate of pay within social care compared to that in healthcare.

We have taken forward a programme of work to make social care a more attractive working environment and to reflect the value of our social care staff, which has resulted in an increase in their pay. Pay has been increased to £12 an hour over the past two years. We have already taken it up to £10.90, and the pay increase in the sector will be equivalent to more than 14 per cent in two years.

The objective behind that is to make care a more attractive profession and to support the retention of social care staff to make the sector more resilient. The principal objective is to try to get more people into care and to support and encourage those working there to remain there in future by providing them with better pay.

Any form of industrial action is hugely disruptive to our NHS, not only to staff and to the management process but to patients. To see that, we only have to look at England, where there has been repeated industrial action and where I believe that more than 7.5 million patients are on waiting lists and that almost a million procedures and appointments have been cancelled as a result. That is the immediate impact, and there will be a cumulative impact caused by backlogs in the system.

The system and staff are already under enormous pressure and adding persistent industrial action to that demoralises staff even further and makes them feel undervalued, bringing all the challenges that go with that. My deal with the junior doctors involved acknowledging and recognising the real challenges that they face because of pay erosion, and we managed to negotiate an agreement with them to avoid industrial action.

My big concern with industrial action is that it is not only disruptive to patients but demoralises people who work in the system even further, which has consequent challenges, and puts people off working in the NHS as a result of the disruption and difficulties.

There is a monetary cost to settling those matters. However, we would create even bigger challenges for ourselves if we did not try to address the issues. The challenges that we would have faced from industrial action would have been even greater—they would have been worse—than dealing with the financial challenges arising from the pay settlement.

NHS Education for Scotland will take forward work on the centre, which was announced last week. Given some of the specific challenges that we have in rural areas around the delivery and sustainability of primary care, as Tess White talked about this morning, the first two years of the programme will focus on primary care, which will be the centre’s initial priority. The centre will start that work as of October.

The burden of disease will continue to increase during the next 20 years by something in the region of 21 per cent, largely because of the demographic shift that we are experiencing as the population gets older. We need to do a number of things to tackle that burden of disease, one of which is to make sure that we are implementing all the right preventative measures to reduce the impact that lifestyle options can have on health. All the public health measures that we take to improve people’s health will be important.

Secondly, we need do all that we can to tackle the social inequalities that drive health inequality, including by tackling poverty and reducing child poverty. Those are key factors in helping to ensure that we focus on preventing ill-health because of social inequality.

Thirdly, we need to continue to develop and adapt our services to meet the increasing demand from older people and people who have multiple conditions so that we can manage their long-term conditions effectively in a way that improves their health and allows the health services to be sustainable.

Prevention is critical, but we also need to adapt our services to meet the increasing demand that we will face as our population gets older. We will also need effective integration between our health and social care services, given that they are critical to one another, particularly in helping older people to manage at home by giving them the support and assistance that they require.

I will probably bring in John Burns to say a bit more about some of the work that we do. The particular challenges that the rural boards face are that they can experience difficulty in recruiting specialist staff because the number of patients that they deal with in some departments means that positions are not so attractive to the staff who need to be recruited to them.

There are a number of reasons for that. For some time now, clinical care has been undergoing ever-increasing specialisation and has moved away from being provided on a more general basis. The general physicians whom we had many more of in the past are becoming fewer and more specialised. That has driven behaviour that results in clinicians wanting to work in specialist centres where there is much more throughput so that they can see the range of patients that they are looking for and build up experience and so on. That is much more challenging in our rural boards, especially given that the population levels are much lower and the boards are not able to sustain the same services.

For a number of years now, we have been putting in place arrangements for managed clinical networks in which we can use clinicians in some of our bigger centres to provide clinical support to boards in our rural and remote areas. Sometimes that involves their going out and holding clinics in those areas, and sometimes it is about supporting clinicians in those areas in their decision making and reviewing of patients. That is one of the ways in which we support our rural and island boards so that they can sustain services. Of course, that sometimes means that patients have to come into the larger clinician centres for specialist care and interventions.

John Burns can maybe say a bit more about some of that work, which has been on-going for some time now.

I do not think that we have ever been at the point where our NHS has been designed; it is a dynamic process and there has always been an element of redesign in our NHS.

I will give you a practical example that I had to deal with in my constituency. Falkirk and District royal infirmary and Stirling royal infirmary both had orthopaedic units, but it became increasingly apparent that, from a clinical perspective, it was not sustainable to have two separate orthopaedic departments. The clinicians said that they did not have the throughput of patients to achieve the teaching hospital status that was necessary to attract junior doctors, registrars and other staff so that the departments could be viable. We have moved from having two district royal infirmaries in the Forth Valley area to having one—Forth Valley royal hospital—which is a single site that provides that function.

It is sometimes the case that redesigns are not driven by the Government wanting to centralise things for the sake of it but are a result of clinical change and clinical demand. The reality is that we are operating in a global market for clinical skills, which means that some services need to be offered in major centres, because they are not sustainable outwith those settings.

I do not want your constituents in rural areas to experience any reduction in healthcare services but, equally, I need to think about how we achieve a balance in being able to meet patients’ clinical needs when it is not possible to get clinicians to work in those areas for the reasons that I illustrated through the practical example from my constituency. In different areas across the country, services have had to be located in a single setting. For example, in the past, we have sought to use managed clinical networks for services such as neurosurgery in Aberdeen. We provided support in Grampian—largely through support from Glasgow and, to some degree, Edinburgh—so that neurosurgical services could continue to be delivered there.

Where clinical expertise and support can be provided by some of our big urban centres to other locations in the country, we have tried to do that and to use that type of design so that we can support rural healthcare. We have used managed clinical networks in some of our Highland areas as well as our island communities for the delivery of certain healthcare services so that we can support clinical services and try to make them sustainable. We will continue to have to be innovative in the approach that we take in an effort to support and retain services in our rural areas as best we can, while acknowledging that there are challenges.

As I mentioned, ever-increasing specialisation is taking place within medicine; it is moving away from the generalist approach that we might have had 30 or 40 years ago. As a result, specialist centres have become more and more important in how clinical services are designed and delivered.

I accept the challenge that exists in your area, and I recognise and acknowledge the concern that you raise. As health secretary, I would not be thinking about redesigning services just for the sake of it and against clinical advice. However, we must recognise that, on occasion, boards have to make decisions on the basis of clinical advice to ensure safe services for patients. We have to take that into account.

We will never get to the point where we have reached a final design—it will always be a dynamic process. We must be innovative because of our large rural areas; we must try to support rural services, where we can, to reduce the need for patients to travel by delivering services as close to people as possible, alongside the increasing specialisation and the need to deliver safe services. We must try to get the balance right, but we might not always succeed and we should not be frightened to admit that—we can revisit such things if necessary. It is a competing balance and one that we have to try to manage in areas such as Tess White’s region.

There is a combination of factors. To go back to the point that I made earlier, one factor is making it attractive to relocate to the NHS in Scotland. I will bring in Stephen Lea-Ross, who can say more about the workforce, but we undertake considerable work through NHS Education for Scotland to try to ensure that NHS Scotland is an attractive employer and that we provide programmes of on-going training, education and support for our clinical staff.

It is worth bearing in mind that we are fishing for these skill sets in a global pool. We have challenges in getting oncologists, ophthalmologists and endocrinologists because there is a global shortage of people with those skills. We must do everything that we can to support and retain skilled people within NHS Scotland.

In terms of medical recruitment into the NHS, in 2022 we managed to fill 93 or 94 per cent of all junior doctor posts, which is the highest number of junior doctors recruited into NHS Scotland since records began. In the last couple of years, we have increased the number of medical places by more than 50 per cent, or 55 places. Is that right?

You seem to have a particular focus on my predecessor.

Our intention is to get there, but it will be challenging to do so in the present financial environment. We will do what we can in this parliamentary session to try to get to that 10 per cent target. I do not have the clarity right now on what budgets will look like next year or the year after that—there is a level of uncertainty about that. However, that is certainly the target that we are aiming to deliver in this parliamentary session and there is no lack of desire to try to achieve it and to ensure that that investment happens in this session.

When a health board puts forward a business case for a capital investment project, it will go through the normal process in Government for considering proposals, but it must be set alongside all the other competing demands in the capital budget—a capital budget that, I should say again, has been cut. We have to balance it against the competing priorities in NHS Scotland and the different proposals from different boards. If the board brings forward a proposal, it will go through the normal process, but it will also have to be considered alongside all the other capital projects in NHS Scotland.