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Could Audit Scotland provide better support to small and medium-sized auditing firms in Scotland that are more localised to their clients and which are spread across your four geographic office areas? After all, four very big international companies are soaking up huge amounts of public money here.

That is helpful and insightful, and I agree with much of what you have said. At the end of the day, the people who are involved are often sick or elderly. People just want the best treatment for their family members and loved ones—they want them to be looked after in the right place. It seems to me that the blockage at that end is causing massive issues in the process, right from A and E all the way through to care. That must be addressed.

The page in your report that struck me the most is page 48, which is in appendix 3. We often get graphs and tables in your helpful reports, and the table on page 48 really stood out as the most shocking one. It is not on A and E but on planned care. The three main targets by which we measure the success of the NHS are on out-patients, in-patients and planned care treatment times—the targets on those are 95 per cent, 100 per cent and 90 per cent respectively. That is ambitious and the targets are high, but not one of them is being met.

In the way that you present data to the committee, we expect to see little green ticks next to any targets that are met. On page 48, not a single health board in Scotland has a green tick next to it. Not a single health board in Scotland is meeting any of the out-patient or in-patient targets. That is shocking.

Okay—thank you.

I want to pick you up on some of the terminology that you are using, because there is a lot of audit language in there. You are talking about efficiencies, productivity and operational management, but I want to get to the nub of the issue. What actually needs to be improved?

More money is being pumped in, which you suggest is getting sucked into pay awards. I do not dispute that pay awards are an important part of public expenditure—nobody around this table would argue against placing value on our public service workers, particularly those on the front line. However, the year-on-year increases in money simply going towards pay awards does nothing to improve outcomes for patients and the public.

What exactly do you mean when you talk about productivity in the health service? What is the Government not doing—or what should it be doing—to improve public health outcomes?

You talk about difficult conversations. Is there an appetite for them?

We can have a national conversation, which I hope will produce some sort of Government vision, which then will produce some form of plan or strategy, which then will be implemented. All of that will take a huge amount of time. With the health budget running at 40 per cent of the total Scottish budget and that level increasing every year, it sounds to me like we are running out of time.

At what point do things become unsustainable? Should anything be on or off the table in those difficult conversations? What sort of things are we talking about here? There are many difficult conversations already happening, but politics often gets in the way of them. Is it fair, for example, that we get free prescriptions? Those are the difficult conversations that we, as politicians, perhaps ought to have, but we are not having them.

Thank you. That was very insightful.

You have segued nicely into my next question, which is on delayed discharge. The report sets out some quite stark figures in that respect. On average, around 1,800 hospital bed days are being used up by people who should not be in hospital—and that is every single day. That equates to around 666,000 hospital bed days per year being used up by people who should not be in hospital. In fact, at its peak, the figure sat at over 2,000 hospital bed days.

That is creating problems—it is creating capacity issues and issues down the line. It is also creating issues for the patients themselves; at the end of the day, there are people—sick people—involved in all of this. Nobody wants to be in hospital when they do not have to be there, and there are people in hospital who do not have to be there—it is as simple as that. Is there any evidence that the Government is tackling delayed discharge, given the number of very high-profile promises that it made to reduce or, indeed, eliminate it? These figures seem to be going absolutely in the wrong direction.

That is helpful. Thank you. We are digging below the headlines a bit more with some of our discussion.

I am getting a feeling of déjà vu in this session. I have not been on the Public Audit Committee for very long, but I have been in the Parliament for eight and a bit years—other members around the table have been here for much longer—and we know that these are perennial issues in our health service.

Auditor General, you talked about the so-called “national conversation” that we need to have about our health service. What should that national conversation look and feel like?

The NHS is sacrosanct in politics. Few politicians or political parties would want to tinker with it—in relation to its structure, how it is funded, or where the money comes from and how it is spent. However, health and social care are fully devolved matters. Therefore, the Scottish Government has the ability to take the direction of travel that it sees fit, in order to make the service fit for purpose and good value for money. I think we all want to see that.

What would you like to see happen in Scotland? What is that national conversation? What are the difficult things that we need to be talking about—as politicians, as a society and as a health service?

There are a lot of questions to ask, and I will probably come back in later. I want to have a conversation about preventative health care and some of the reforms that you have talked about, which may improve outcomes down the line as opposed to just costing more money.

I draw attention to exhibit 5 of the report, which I found quite interesting. When digging below the surface to work out why health boards are running out of money and why so many of them face deficits and are borrowing money, I read about “prescribed drug costs” and “staff costs”, which goes back to my first question about pay increases and what is driving them. Has Audit Scotland done a piece of analysis on the main drivers of the current situation? Is it simply due to pay awards and the increased cost of drugs from pharmaceutical companies, or is there something else that we are missing?

James Dornan raised some important issues there. I want to carry on with that theme, and particularly A and E. As has just been mentioned by one of your colleagues, Auditor General, we are sitting at around 70 per cent of the target of being admitted, discharged or transferred for treatment within four hours. However, we know that there is a huge disparity across the country in how quickly someone will be seen, depending on where they live and the hospital that they are taken to. In NHS Forth Valley and NHS Lanarkshire, that figure is as low as 54 or 55 per cent of target, which is shockingly low. However, NHS Tayside and NHS Western Isles are at 90 per cent and 96 per cent respectively.

I can speak only from my own experiences. In my health board, my local hospital is Inverclyde royal hospital, and the figures there are quite stark. There has been an 8,000 per cent increase in people waiting in A and E for more than four hours and a huge increase in those waiting for more than 12 hours. Is there any understanding of why there are such huge health board disparities in NHS A and E waiting times?