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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.

Health inequalities and the illnesses that are driven by those are the result of social inequality so, very often, our health service is dealing with the symptoms of social inequality that manifest themselves in health inequalities. It is important that we take forward programmes such as reducing child poverty—through, for example, the Scottish child payment. All those will have an immediate benefit for the individuals concerned, but they will have a long-term benefit in reducing child poverty, which can result in health inequalities.

In addition, through the work that we do on tackling tobacco use, there have been reductions, and we want to continue to build on that. On alcohol misuse, a report that was published today by Public Health Scotland shows that minimum unit pricing has helped to reduce alcohol-related deaths by more than 13 per cent. All those factors play an important role in supporting us to prevent ill health, alongside our social policy actions to tackle social inequality. All that will be critical to supporting us in the preventive agenda in health.

I am absolutely confident that we will do everything that we can, but I will not sit here and say that all the financial challenges in NHS Scotland or the public sector will be magicked away—that will not happen. Across the UK, we are going through a period of austerity in the public finances, which is having an impact on our budget and means that we must try to manage the finances as efficiently and effectively as possible. You can be assured that we will do everything that we can to provide financial support where possible, but that will be within the limits of what is available to us to invest in the health service and other public services.

Obviously, inflation is having an impact on the NHS across a range of areas. From procurement of food through to drugs, equipment and maintenance costs, all areas of the NHS are, by and large, impacted by inflation costs, alongside energy costs. That is placing a very significant strain on NHS budgets.

I will get Richard McCallum to say a wee bit more about PFI and the inflationary impact. Inflation is having an impact across a range of areas within health and social care, outwith PFI.

There are a couple of points to make in that respect. First, NHS Scotland has, like the rest of the NHS across the United Kingdom, used agency staff at various points. If you look at the figures, you will see that over the past 12 months there has been a bit of a spike in the number of agency staff being used. Greater use of such staff largely reflects the significant recruitment challenges that the NHS faced over the course of the pandemic. In the past month, we have applied additional restrictions on boards in order to reduce our agency spend. To put that in context, though, I point out that our agency spend is a relatively small proportion of our overall budget: I think that it is less than 2 per cent.

If there is a need for flexibility in relation to staff, we would much prefer to work with NHS bank staff who are on NHS contracts and NHS terms and conditions. We have applied some restrictions on boards to make sure that they are focusing much more on using bank staff where necessary.

We must also make sure that the NHS is an attractive place for staff to work. That is why the agenda for change settlement was critical, through taking forward measures to address issues related to pay and conditions in order to ensure that NHS Scotland is seen as an attractive place to work and to take one’s career forward.

Work was also done through, for example, the nursing and midwifery task force to improve recruitment to and retention within NHS Scotland.

Those are all areas of work that are about retaining staff within the NHS and making it an attractive place to come and work. It is also about looking at new routes into the regulated professions.

Reform around workforce, training and planning, alongside work on pay and conditions and much greater focus on use of NHS bank, rather than agency, staff are all part of the combination or package of measures that we are taking forward to reduce our dependency on locum and agency work.

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.