threshold I live, very much good morning and welcome to the first meeting of the Health and Sport Committee in 2019, I hope everyone is fairly refreshed, if you can still remember Christmas New Year then congratulations and welcome back. Can I ask everyone in the room to please ensure that mobile phones are switch off or to silent. We have received apologies, this morning, from Ale called Hamilton and from David Stewart I welcome Anna Sauer as substitute for David Stewart at this morning's meeting. In accordance with section 3 of the code of conduct, I invite Anna Sauer to declare any interests relevant to the remit of the committee. Any declarations should be brief but sufficiently detailed to make clear the nature of any interest. Anna Sauer, I have nothing to declare except to say I am a former NHS dentist. Thank you very much and welcome to the committee. The next item of our agenda is an evidence session on the draft budget 2019-20. The committee's approach to scrutiny of the draft budget reflects the approach that is recommended by the budget process review group. That entails addressing budget implications throughout the year and bringing this information together to inform our pre-budget report for consideration by the cabinet secretary. Members will recall that we issued our pre-budget report on 29 October. That report set out some recurring themes and issues that we had identified in relation to the Scottish Government's draft budget. The timing of the report in advance of publication of the draft budget was to enable the Scottish Government, if it chose, to endorse our recommendations to implement them in the draft budget. A response to a report was received from the cabinet secretary on 21 December. Absolutely on cue, I welcome to the committee the cabinet secretary for health and sport, Jeane Freeman, the director general of health and social care and chief executive of NHS Scotland, Paul Gray and Richard McCallum, deputy director for health, finance and infrastructure. I invite the cabinet secretary to make an opening statement. Thank you very much, convener, and good morning to you and members. I welcome the opportunity to give evidence this morning on the budget proposals for our health and care services. The emphasis in this budget is ensuring that resources are directed appropriately in support of our front-line services. It is our outstanding health and care staff who deliver those front-line services, and I want to take the opportunity to pay tribute to them this morning, in particular to the hard work that they have undertaken over what has been another busy Christmas and New Year period. The budget for 2019-20 supports the medium-term financial framework and sets out the next steps in our financial plans. When I outlined a framework to Parliament back in October, I made clear that all resource consequentials would be passed on in full, and when I said that and I quote, in finalising the financial framework, I have made the perhaps bold assumption that the UK Government will honour its commitment, deliver the consequentials as a true net benefit and not reduce the Scottish Government's funding by cuts applied elsewhere or by other measures. I was therefore disappointed and concerned about the potential impact on our spending plans when the UK autumn budget confirmed a reduction in health consequentials of £55 million for 2019-20. However, as part of our proposed budget, the Scottish Government has both passed on resource consequentials in full and provided additional funding of £55 million. That reinstates the UK Government's reduction and protects the resources for our front-line services. The Scottish budget for 2019-20 sets out total investment for health and sport portfolio in excess of £14 billion and provides a further shift in the balance of spend towards mental health and to primary community and social care. In 2020, our investment in social care and integration will exceed £700 million. That is an important next step in delivering our commitment that, by the end of this Parliament, more than half of spending will be in community health services. We will invest an additional £430 million in our front-line NHS boards, which provides an uplift of funding of 4.2 per cent in cash terms. We will continue our policy of supporting those boards furthest from NRAC parity and we will invest £23 million to ensure that no board is further than 0.8 per cent from parity in 2019-20. We will provide funding of £392 million to improve patient outcomes. That will support our waiting times improvement plan and will lead to sustainable substantial improvements to performance, including the aim that, by spring 2021, 95 per cent of outpatients and 100 per cent of inpatients will wait less than 12 weeks to be treated. Our investment in improving patient outcomes will take overall funding to £940 million to support the Scottish GP contract and the reform of primary care, continuing to support health and social care integration and allowing GPs more time to spend with those who need it most. In terms of sport, the budget supports the people of Scotland to become more physically active as part of our efforts to prevent ill health and improve wellbeing, while delivering world-class sporting performances. In 2020, Sport Scotland will receive additional funding of 3 per cent in cash terms, taking their overall budget to £32.7 million. We will continue to underwrite the potential shortfall in lottery funding of up to £3.4 million and will continue to encourage the UK Government to take the necessary actions to address lottery reductions. In terms of capital, capital investment in 2020 will amount to £336 million. That includes investment in the Baird family hospital and the anchor centre in Aberdeen and will support increasing elective capacity across the country. Members will be aware of my intention to bring a capital investment strategy to Parliament by the end of this financial year. That new strategy will create a framework considering necessary investment over the longer term and will accompany the medium-term financial framework. It will include important investment in primary and community care projects, which will be key in delivering the emerging health and social care integration agenda and continuing to shift the balance of care from hospitals to local facilities and people's homes. In terms of the planning and performance cycle, 2020 will be the first year of our new planning and performance cycle. In return for their efforts to deliver the reforms set out in the delivery plan and the financial framework, boards will be required to deliver a break-even position over a three-year period rather than annually, as is the case currently. In each year, boards will have 1 per cent flexibility on their annual resource budget to allow them the scope to marginally underspend or overspend in that year. In order to give all our territorial boards clear ground to move forward, as members know, I will not seek to recover their outstanding brokerage. That is money that has already been spent in providing patient care and has been accommodated in the overall health and support portfolio budget. In conclusion, the Scottish budget for 2020 passes on consequentials in full to health and care, with the additional support to ensure that the money anticipated from the UK Government is now met with additional funds from the Scottish Government. It goes over and above that to protect the plans set out in the medium-term financial framework. The spending plans are supported by greater flexibility to assist boards in planning beyond one year and to consider key areas of investment, such as in relation to primary care, mental health and waiting times improvement. That will support our boards, along with integration authorities, to deliver the measures set out in the delivery plan and the financial framework in a safe and appropriate way, making sure that they maintain a strong focus on care and the delivery of services that are safe, effective, person-centred and timely. I commend the budget to the committee and, of course, answer any questions that members may have. Thank you very much, cabinet secretary. That is very helpful. Clearly, since the process of this year's budget began, there have been quite a number of changes in the way in which financial information is presented with the medium-term financial framework and other innovations, which the committee has broadly welcomed. Can I ask about one aspect that stands out from the tables presenting level 3 spending plans? That is the way in which planned efficiency savings are concentrated under a single line under the miscellaneous services. The consequence of that clearly is that that line stands out as being the one area of reduced spending. I think that the committee would be keen to understand how that will work through in terms of impact on spending lines over the course of the financial year. The efficiency savings appear to be concentrated in one place, but presumably will be dispersed across the department and we would like to understand how that is likely to impact on what are otherwise real terms increases in some of those spending lines. Perhaps two or three things that it would be helpful to set out on that. The first thing that the committee might find helpful to note is that we always start the year with a level of efficiency savings that we need to make at a portfolio level, and that was the same in 2018-19 as it is in 2019-20. We take this approach as a prudent approach because there can be slippage on certain programmes and there is the opportunity for savings that might occur. This is an approach that recognises that. If I think about the 2018-19 budget and where we have got to this year with some of those efficiency savings, it is on specific programme lines that are under the departmental allocations line, so it is things like our digital programmes, the costs associated with NPD, which can fluctuate and go down. It is in relation to clinical negligence costs, which also tend to go down and slippage on some of our other programmes. It is the most prudent approach to have it on that single line. We would not want to apply hard and fast savings to each budget line. That would not seem a proportionate approach, and we work with each directorate and policy area that is taking those programme lines forward to support them without work. I guess that the most important thing is in our core areas of spend, whether that is primary care or whether it is mental health or whether it is waiting times improvement. We would not see those efficiencies being applied to those lines. We would be keen to see those move forward as we have set out in the budget. You are saying that you make pessimistic assumptions about areas such as the cost of NPD, the cost of medical negligence, and then look to achieve efficiency savings from the pessimism impact, if you like, or the impact of what actually comes through. That is correct. We would start with a figure that we think it could be, and it is generally a more pessimistic scenario. Through the year, we see if that will play out as we expect or not. The only thing that I would add to that, convener, is that officials work through that in this way, based on their knowledge of how programmes have performed in previous years. Yes, indeed. Thank you very much. I am interested in issues around community spending and primary care, and how you are describing that half of the spending will be in communities. I am aware that there is a lot of work being done, especially locally in Dumfries and Galloway, to support primary care and the Transform and Wigdanshire programme, for instance, to look at better ways of health and social care integration and care in the community. I am interested in the fact that the budget is 9 per cent of the current primary care, with a target of 11 per cent. That target seems to be pretty reasonable. Do you think that it is ambitious enough for transferring money into the community and primary care? As you rightly say, our target is to reach a position where 11 per cent of NHS budget is in primary care by the end of this Parliament. At 9 per cent in the current draft budget, we are certainly on track to deliver that. I would want to hold to that position in this financial year and to look in the next financial year in the budget that comes forward then, whether we want to, based on performance, increase our ambition for that 11 per cent. At this point, the prudent approach is to say that we are well on track to meet our commitment of 11 per cent. I need to see how well we deliver improvements in areas that are effectively hospital-based care, particularly around the waiting times improvement plan. If that plan is delivered against its trajectory and depending on where the financial situation is in 2021, we may want to increase that target of 11 per cent. At this point, it is prudent to stay with it and to say that we are well on track to meet it. Next question is about community hospitals. In the budget proposed, the community hospitals were part of the community budget, which is probably pretty reasonable. As my understanding, as a former NHS employee, many community hospitals are managed by local general practices. That seems reasonable that community hospitals will be part of community spending and not acute care spending. Is that correct? Yes, absolutely. Community hospitals are, as they say, located in the community and should be part of that overall shift in the balance of care and also be part of making sure that people are in the acute setting for the period of their clinical need and for no longer. I know from some examples that some of our community-based hospitals are used as both step-down and step-up care. Some perform a re-enablement function, as well as other areas. There is a range of ways by which community hospitals can contribute to that shift in the balance of care from the acute setting to the community. My final question is whether you think that the Scottish Government could commit to publishing updates on progress towards various commitments as part of the budget document. I appreciate knowing perhaps which ones you might be thinking of. We currently publish on a monthly basis where our boards are in terms of their financial position and quarterly in terms of the IJBs. The waiting times improvement plan commits to advising Parliament in clearly this committee of progress against the milestones that it sets. I understand that there are similar sets of commitments in terms of our additional investment in mental health, so, if there are other areas, we are certainly happy to consider that. For me, it is handy to get on the record that we have the reports that are currently published, whether it is monthly or quarterly, as required. I want to make sure that we have that on the record. I noticed, cabinet secretary, in the opening remarks about the Banach consequentials and the shortfall, that I raised and I have actually written down, could this see reductions in the future? Have you had any assurances from the UK Government that there will not be future reductions, because you are talking about 55 million pound reductions? Well, no, we have not had any assurances from the UK Government. They made a commitment in June, which was not then honoured later in the year that left us with a 55 million pound shortfall. That Government's commitment is to make that good on a recurring basis. Obviously, we will continue to press the UK Government to revisit its position, but we generally all be agreed whatever our position is that, right at the moment, on this date, we are a bit uncertain what the future might look like, but we are certain that this Government will continue to meet our commitment on that shortfall. I would like to follow on from what Sandra White was asking about the Banach consequentials. I was glad to hear that you said that all resources would be put straight into the NHS with regard to the consequentials, but it is disappointing to see that there is a 55 million pounds black hole. It is almost as if the Westminster—I like to keep things quite simple, cabinet secretary—you know that, and it is almost as if the Westminster Government has picked the pocket of the health service to the tune of 55 million pounds a year. When you look at that, I am glad that the Scottish Government is actually taking that 55 million pounds and they are covering it, but the whole scenario is that when I was reading this over the weekend, the question that kept coming back in my head was what would be the impact on the health service if the Scottish Government hadn't actually made sure that that 55 million pound a year was available? Well, if you look, for example, at how the additional monies are going into front-line spending, then additional in 2019-20 in terms of the work of our work on elective meeting those targets, then there is additional money going in there, which is an example of some of the difficult decisions that would have had to be made. The commitment on mental health is another. The commitment is that there are significant areas of additional spend, primary care reform, of course, and transferring the funds in terms of the balance of care towards community care. The additional resource that is going from the health budget into local government for integrated health and social care is around £120 million or £30 million in order to ensure that we implement Frank's law in the widest sense to everyone under 65 and so on. There are a number of examples of where, if that shortfall had not been made by the Scottish Government, we would have had more difficult decisions to make than we currently have. However, the other side of that is also to say that having made good that shortfall from the overall Scottish budget in a situation where the Scottish Government's budget is significantly reduced, puts pressure elsewhere. The money has to come from somewhere. It should have come from the UK Government, because that was the commitment that it made. It did not honour that commitment. The Scottish Government has worked to make good that shortfall, but that puts pressure elsewhere in the Scottish budget, a Scottish budget that is already significantly reduced as a consequence of the UK Government's decisions. Many of the issues that you mentioned and services that you mentioned during your first answer are things that we all support regardless of political parties. Effectively, is it not the case that, if you vote against this budget, you are not only just going against the £55 million extra that the NHS provides to the Scottish Government, but you are actually going against supporting all those things, like Frank's law, such as the other campaigns that we have had here? Is that not the case that you have taken a very pragmatic view to actually see that we could push things forward? Clearly, we are not here to discuss the votes for or against the budget. That is a matter that you can use your discretion as to how far you go down that road. Clearly, we want to know the evidence that you are able to bring forward in support of your budget proposal. Absolutely, convener, and I completely appreciate that. The simple fact is that, at the end of the day, the committee will have views that it wants to express in terms of this part of the draft budget. Parliament as a whole will make decisions on the overall budget, but what I am saying very clearly is that, if the health and sport portfolio has less money than is currently in the draft budget, difficult decisions need to be made, and those are around areas where there is a significant level of spend, be it in mental health, be it in addiction work, be it in the extension in terms of Frank's law. I am sure that every member of the committee is cognisant of that. There is no money hidden anywhere—it is here—and, if that is not supported, those difficult decisions have to be made about what cannot be afforded. On the back of what the cabinet secretary said in answer to Sandra White, when you mentioned the fact that Sandra asked whether it was a case of, if you get any guarantees from the Westminster Government, will there be other ways that they will find to make sure that there is no barn that consequentials when you get further cuts, has there been any guarantee that they will not continue to go down this route to find ways to attack Scotland's health service? In terms of overall funding from the UK Government that comes as a result of consequentials, there is no guarantee beyond where we are in this current year. Of course, there may well be a subsequent UK budget, depending on how decisions play out with respect to Brexit, as the chancellor himself said. He may need to come back in his view and introduce another UK budget, so we cannot be sure. There are no guarantees, nor can we be sure in what way, if at all, the position may change. Can I take you to the medium-term health and social care financial framework, which was published towards the end of last year, which was very helpful? I wonder whether you can lay out for us what level of savings will be expected in 2019-20 from health boards and from integration authorities. Members will see the nature of my briefing. Trust me, I have read it all, but it is not always straightforward for me to find exactly the bit that I need. The financial framework indicates health demand pressures of up to 4 per cent above inflation, and the level of savings that is required from the boards in this current financial year is not here in front of me. Do you have it? We are still working through with health boards. They will have received the budget and they will be working through their financial plans for next year. We expect the savings that boards require to be of a similar level as in 2018-19 and 2017-18, but that is something that we will be working through with boards over the course of the next couple of months. For a ballpark figure to understand the rough territory in which you are talking, what is the current year's level of savings and how far do you expect that to be increased or repeated? Health boards are making about 4.5 per cent of savings in 2018-19. It is in that sort of territory that you anticipate savings in the coming year. I will make a point that is often misunderstood because we talk about savings. The boards hold that money, so they use it to reinvest. I know from my own experience at Golden Jubilee that when you make efficiency savings or other savings in terms of how the board delivers its work, what you are doing is, in effect, using that resource to apply to another area of the board's activity. It is not money that comes back into central government. I understood, but in your financial framework you laid out an expectation of £1.7 billion in savings by 2023-24. How far do you believe that the budget keeps you on track for that medium-term target? It keeps us on track. The budget has been devised and negotiated with the finance secretary to be in line with the medium-term financial framework. Obviously, he and his officials contributed to that medium-term financial framework at the point that we were pulling it together. The financial framework suggested that, even in that context, there may still be a funding gap of some £159 million. What is your expectation in terms of addressing or filling that funding gap? That work is under way. It requires considerable consultation between ourselves and major groups of clinicians, boards and, of course, our local authorities to look at two things. One, how effective we are in the coming period in continuing the reform of delivery and shifting the balance of care from acute to the community setting, but also in the delivery in the acute setting. We are anticipating the level of spend in the light of those reforms in delivery that do not diminish at all either the patient experience or patient outcomes against the level of demand. We think that there are ways in which we need to either make some difficult decisions in the longer term or ways in which we think that we need to secure additional resources in order to meet the shortfall. My feeling at this point—I should stress that it is only a feeling—is that it will be over time, over the period of the medium-term financial framework and the years that we have set out there, a mix of looking for the re-prioritisation of our existing resources, some additional resources and some deliverables in terms of better use of resources when we fully reform the process. Thank you very much, convener. Good morning, Cabinet Secretary and Mr Gray and Mr McCallum. You will be aware that the committee, on previous occasions, has looked to the year-end concern about the reliance on the in-year allocation budgets to health boards. I note that health boards are the national boards. I have received an increase and it will be topped up in other boards by various other departments to health boards in the in-year department allocation. We have raised before about whether it would be better that health boards get the monies at the beginning of the year rather than in-year allocations. Obviously, one of the questions that we want to be asked is whether the budget would be better if the money was earlier rather than later. I wonder whether the cabinet secretary agreed with the reliance on in-year allocations that the committee has raised to hamper the boards' ability to plan over a longer-term framework? Would it, in fact, be more helpful to allocate funds at the start of the financial year? I understand the question. I need to say that, in the draft budget, 90 per cent of what boards will receive is in their baseline. That is a significant amount of money. In terms of planning, we have taken the point about prudent financial planning should be over a longer time frame than a year, which is why we have set the three-year financial planning framework for boards starting from 1920. I think that there needs to be a balance. Boards are receiving 90 per cent in terms of their baseline funding, so they know what they have to deliver their services against, and they can plan for that, including in that, of course, being able to meet the commitments on workforce pay and so on, and plan maintenance and other matters. However, I am also very keen that, where we have specific areas of work that we have set as a priority—I think that here—of waiting times and of our significant commitment and the resource that backs it on both waiting times and mental health, we fund two results. What I mean by that is not that you have to deliver the result and then we give you the money, but I want to know that, if a board is receiving £2 million, exactly what will be the impact of that on how many patients in order to reduce waiting times in what specialisms? I think that there needs to be a mix in which boards have a significant degree of certainty about the funding that they are working to, which is 90 per cent, but we also very vigorously perform and manage additional resources that are going to delivering services for patients against anticipated outcomes. Therefore, we use the resources and we flex them across the piece. If you look, for example, at some of the work in terms of waiting times, not every board is in exactly the same place in terms of meeting or not those targets and in terms of which specialisms they may be successful in and others in not. It is not a consistent picture across the country. I want to be able to use that additional resource in a targeted way to get to a consistent position across the country where we are meeting those targets. Boards know that there is additional resource, for example, to meet waiting times or to deliver on the mental health commitments, so they can anticipate that, provided that they have the propositions in place that can evidence what they will additionally do and therefore additionally deliver, the resource will be made available to them. I thank you for that because you mentioned that particular issue in your opening remarks. I just wanted to, for my own self, to get a wee bit more information regarding that in 2020. In other words, you have listened to the committee as well as put forward the ideas that you have to have that extra 10 per cent to make sure that the boards fulfil what the Scottish Government, whatever make-up it is, is going forward. I do thank you for that. There is just another question that I wanted to come in on. What funding will be made available for Public Health Scotland in relation to extra funding for Public Health Scotland? Will that reduce the budgets elsewhere in the health portfolio? Public Health Scotland is due to come into being in the next financial year. It is based on shared public agreed standards and objectives with COSLA. We are in the business in the middle at the moment of appointing that. Public Health Scotland will then take a significant role in helping us deliver in some of the areas that are already in the budget, for example, around the diet and healthy weight strategy and some of the addiction work and so on. It will have a responsibility in terms of assisting in the delivery of those. The resource that it would require is already being set out in some of the budget information that you already have. That aside, it will be considered as a national board and will receive some core funding. I would anticipate that core funding is at a level that is not then seen at levels 3 in the budget. The new body, as the cabinet secretary has said, brings together work that is done in a number of places, including in health Scotland at present and also in NHS national services Scotland. In response to your specific question, is money being taken from other places to fund this? The answer is no, because we are using the money that currently exists. However, the co-ordination that the new public health body will provide and the ability to work much more effectively with our partners, including local authorities, we believe will produce better outcomes in terms of public health and population health overall. I want to focus on service reform on a capital spend. One of the Audit Scotland findings was a severe backlog in terms of capital investment and maintenance required in our hospital buildings, more and more going into the danger zone. How does that tie up with a reduction in the capital investment and what priorities will be set out in the strategy that is to be outlined later on this year? As you rightly noticed, our allocation in terms of capital is limited and it will cover some of the areas that I set out earlier. It is 5 million short of the previous year. There are 188 million in core capital, and 52 is there for elective centres. In terms of backlog maintenance, that has come down since 2015 to the most recent figure of 2017, but it remains a significant area for us to work through with our health boards. Although we have made some commitments in terms of new capital spend, we have to work with the boards in terms of the backlog maintenance and the risk profile around that, where we have about 10 per cent of high-risk, and that is the area of significant focus that we are undertaking with boards. In terms of high-risk, looking at the allocation in the budget on capital investment, my guess is that the capital investment that we are making to expand will not cover the high-risk that is being identified. In this year, do you expect all the high-risk maintenance backlog to be cleared? If not, in this financial year, by when? The core element of the capital budget covers maintenance and the priority in the areas to address high-risk maintenance areas. We would expect those to be addressed in this financial year, and we will be working with boards to ensure that that is the case. You then move down, if you like, the priority list into significant. Once we have completed the discussions with boards, we will understand better what proportion of that significant risk area in backlog maintenance we will be able to address in this financial year, and that will then give us the trajectory forward. Just to clarify, do you expect the next financial year report on backlog maintenance and high-risk to have been cleared based on the capital investment commitments that are made in this budget? I would expect the high-risk areas to be cleared, yes. Following on to service reform from Mr Gray's and I's exchanges in the Audit Committee, one of the issues that constantly comes up is around organisational reform, as well as service reform. We are just focusing on organisational reform for a moment, because there is a direct link between how the organisation is run and its delivery in terms of its budgets and its maintenance. An issue that has come up regularly is the leadership around a lack of leadership figures, a lack of the adequately skilled individuals, either to run health boards or to be executives for health boards. What action is the Scottish Government taking to improve the leadership of NHS Scotland in terms of health boards? How much of that is greater integration of health boards? Let me deal with the last question first. I will ask Mr Gray to talk a bit more about the specific programmes that are under way in some of the discussions that we are having with our colleagues in COSLA around leadership in integrated joint boards. I know that you will know that Audit Scotland touched upon when it produced its report. My primary focus at this point is to ensure that our health service delivers on the commitments that we have made, that it remains safe, effective and person-centred, and that, in particular, we meet those commitments on mental health and on waiting times. I know and I know that you will too that when you embark on a major organisational restructuring, inevitably what happens is that people take their eye off one particular ball in order to worry or position themselves about where they may be in the new world. I do not have time for them to do that. My focus in this parliamentary term is on delivery. What a future Parliament or a future Government might do is for them to decide. They may want to build on the regional working that has been long-existent in NHS Scotland, which is part of how we look at reforming the delivery of services in order to get the best clinical outcomes. They may want to build on that, but they may not. Right now, in this Parliament, I have no intention of reorganising the structures around our health boards because I need everyone focused on delivery. I agree with that. I think that we all agree that the focus has to be on delivery, but if we accept the challenges around leaders, if we accept that getting adequate number of people to fill the roles that are required, do you envision more shared roles across health boards? For example, more shared financial officers, more skills training for individual health boards about how they manage their budgets and look at the brokerage issues, for example? Do you see more shared roles taking place? We already have some of that under way, and Mr Gray will talk about where that is taking place and what we learned from that. There may then be the opportunity to increase or scale that up, but that is about the effective use of the existing resource that we have, so that everyone keeps their eye on the delivery ball. First of all, let me deal with the point about adequate numbers. The cabinet secretary has just appointed chairs to NHS Grampian, NHS Western Isles, NHS Dumfries and Galloway. When people have said that they were going, we have gone through the appropriate processes, and new people have been appointed. We have just appointed a chief executive to NHS Highland, who will start at the beginning of February. They have an interim chief executive for one month. As I was trying to do at the last committee session, I want to make it clear to the committee that, with the cabinet secretary, we plan ahead for what is coming. We are showing by those appointments that those plans bear fruit. In terms of leadership at executive level, the committee will doubtless know from documentation that we have provided elsewhere that, for example, Alan Gray, who is the finance director in NHS Grampian, is also providing support in NHS Tayside. That is entirely appropriate that one of our most senior and experienced finance directors should assist a board that needs support. As we look ahead, there is definitely opportunity for some joint appointments. There are, for example, joint appointments already in Orkney with local Government at finance director level, similar considerations in Shetland. Where a joint appointment is appropriate, that is considered and where it is efficient and makes sense, and where the experience is valuable. In terms of the leadership development, perhaps I will not go into too much detail today, but I can send the committee details of project lift, which is our leadership development programme that has recently been implemented to ensure that we are not only developing the leaders who are currently in post but those who may come forward to more senior positions. The Scottish Leaders Forum takes collaborative leadership very seriously as a core component of the learning of leaders in the public sector for precisely the reasons that the Cabinet Secretary has said. This is not all about structure, this is about the way people lead, the way people are able to lead across boundaries, that ministerial steering group will meet shortly co-chaired by the Cabinet Secretary and the COSLA lead for health and social care. They will consider the recommendations that are coming to them on the further development of integration within that. Clearly leadership will be considered. That, again, is about joint leadership. I think that if we take our eye off the delivery ball at this stage, we are actually backing away from what we think is most important, which is the delivery for citizens and also backing away from the importance that we attach to collaborative leadership, which I think is fundamental to delivering what we need. Sorry, can I just add a couple of things? We would be very happy to send the committee this information in addition to what Mr Gray said about various leadership programmes that are under way. There are other examples of joint roles. For example, my understanding is correctly that we have a joint role in terms of nurse director between NHS 24 in Dumfries and Galloway, and finance director at Golden Jubilee has a joint role with one of our other national boards, so we will make sure that the committee is aware of where that sensible joint working is under way. Of course, as that demonstrates itself to be effective, there is the opportunity to widen that. I turn on the focus back to delivery in terms of service reform. How ambitious Cabinet Secretary, will you be allowed to be and do you intend to be when it comes to service reform? That is a suitably open-ended question, Mr Sarwar. I think that I am pretty ambitious. I am not sure who might stop me unless the Parliament disagreed with what I wanted to do. I think that one of the examples of that work—I know that members will be very familiar with the idea of collaboratives and quality improvement and so on and how we undertake that work—has struck me. It is not news to anyone that we have across the piece, and it is not particularly in health. I think that it is a 20-year-old tradition in this place that we have an overfundness for pilots, which I do not share. We have excellent examples of good reform in the delivery of services that is led from the ground up by clinicians, medical staff and others who are working in our health service. I can think of some examples where those reforms have actually been driven by our reception, importer and other staff, where it works very well and then we cast out an optimistic hope that good practice will be shared. My intention is that good practice is applied and we do not simply hope that someone shares it. In the waiting times improvement plan, for example, you will see that there are a number of measures, both to reduce the current long waits but to do that in a way that is also sustainable into the future. We turn to a similar place. We have brought into that the work headed up by Jason Leitch in terms of our quality improvement programmes and the numbers of individuals that we have across our health boards who have led service improvement and reform in order to make sure that we can upscale that. We have really good track record in that area if we look at the Scottish patient safety programme. I want to see that replicated in some of the service reform in the health service but also then working with local government in terms of our iJBs. I have begun some initial discussions with councillor Curry, who is the cosla lead in this area, on how we might do that using some of their experience in working with Government in the children and young people's collaborative, for example. I think that we need to move on if you have one final. I am just going to say in a friendly way that we know you are ambitious. We also know you are ambitious for the national health service as well. Just in terms of some service reform, do you intend to come to Parliament with a service reform programme to try and get the support of Parliament to build public support around a reform agenda that helps service delivery, particularly while we focus on the budget, a lot of the challenges that we face around workforce issues rather than budgetary issues? If we are to have a service that meets the workforce that we have as well as the ambitions that we have for delivering healthcare, that requires some fundamental reform. Do you intend to come to Parliament with a radical reform agenda around our NHS and health and social care services? At this point, the sensible thing for me is not to absolutely commit to that until I have continued some of the really important discussions that need to happen, for example with our colleges and our boards, as well as some of our other colleagues. I am not saying no to it, but I think that it is foolish to commit to doing it until I am sure that we would have a radical reform plan inside this parliamentary term that I would be confident that we had support from some of the key deliverers of it that I would want to bring to Parliament and have that wider discussion. There will be those recommendations in terms of health and social care that Mr Gray has touched on, and I will make sure to inform Parliament about how ourselves and COSLA intend to deliver on those recommendations. That would be one part of it, but not necessarily the totality of it. We are moving on to a three-year financial planning framework model. I wonder what practical changes will that move entail. Also, when do you expect boards to be provided with an indicative allocation over that sort of three-year financial term? In terms of practical improvements, I think that what that allows boards to do is in practical terms look over the horizon of three years. In some of the areas of delivery reform that Mr Sauer and I have just been touching on, that allows them to plan improvements in delivery and service redesign that may not be as easily done within a 12-month timeframe as it may be within a 15-month or 20-month timeframe, and to anticipate their resourcing accordingly. I think that boards can reasonably anticipate that their core funding, at the very least, would remain stable. However, as you know, as a Scottish Government, we do annual budgeting, so I cannot give boards figures for anything beyond 1920, but they can reasonably anticipate where they might go in 2021 and so on. The practical improvements that I expect to see at board level are the flexibility that they have asked for and that would now match the flexibility that IJBs have, because they benefit from the local authority arrangements in terms of reserves and flexibility. That flexibility now extended to boards would allow that better integrated and forward planning. In terms of practical changes for us as a Government, that allows those more detailed conversations around service redesign that we touched on. I expect to see that scaling up of improvements. The waiting times plan is a 30-month plan, so boards can be planning what they need to do over that 30-month period in order to deliver the results that I require of them. Here, our financial monitoring and performance monitoring arrangements will be flexed in order to ensure that we are working with boards to ensure that at the end of a three-year period, they reach balance and that the flexibility that they have in-year is one that they are using as judicially as possible. If we are moving to the three-year financial planning framework, if you are unable to give the health boards indicative finances to work to, how is that a three-year financial planning? How can they possibly plan if they do not know how much money they are likely to be allocated over a three-year period? I do not know what the Scottish Government's budget will be in 2020-21. I do not know that because the UK Government does not work on those longer terms, so we do not know what the Barnett consequentials will be and we do not know where our starting point would be as a Scottish Government. We cannot do that as a three-year financial plan. What I said was that I could not give boards figures for 2021 or 2021-22, but we can say to boards that they should anticipate that their baseline funding in 2020 will not be reduced when we get to 2021. They have a degree and I am certain that a degree of common sense and financial expertise would allow them to do that. Presumably, the UK Government is moving on to a multi-year financial planning. You will be able to tie that down a bit tighter than that. If that is what they did, then that would be for Mr Mackay to decide how he wants the Scottish budget to go forward. If I move on to brokerage, there will be a brokerage of £151.6 million across four boards that was underwritten for one of the better expressions by the Scottish Government. You are saying that you are looking for a break-even position over three years. I wonder if you are confident in that particular outcome. Just for clarification, are we looking at a break-even for the three years or are we looking at a break-even for year three, if that makes sense? You are going to break-even over three years over the three-year period, whether it be a loss in the first couple of years and then making that shot for year three, or are you looking for a break-even by year three? I am looking for a break-even by year three. Okay, because we know, for example, that Ayrsyn Arran has already indicated that they will require brokerage over the next three years, so they are suggesting that they will not meet a break-even in three years, so does the Scottish Government underwrite that brokerage as well? The brokerage that they have said that they require over the next three years is a continuation of the brokerage that they require in this year. What I have said to them is that they are not required to repay that after this year. From 1920, the brokerage that boards have been given will not be required to be repaid to the Scottish Government, so they start with a clean slate. I understand that, but I also understand from Ayrsyn Arran that, even with their clean slate, they will still require brokerage going forward for the next three years. That is not my understanding from Ayrsyn Arran. My understanding from Ayrsyn Arran is that their requirement of brokerage over the next three years takes account of the fact that they need it this year. They are anticipating, over the next three years, at the point where they said that, that having to pay that back has changed. That situation has changed. I suggest that you and I have got different information, Cabinet Secretary, and we may have to clarify that. We may indeed. On that point, Cabinet Secretary, clearly the decision on brokerage is one that we are familiar with. What is your anticipation of the financial position for boards that have not received brokerage? Are you confident that all those boards are in a place where they will be able to continue to break even on a year-by-year basis? Yes, I am. Thank you very much. I suppose that an additional point in relation to that is around monthly reports. You mentioned earlier monthly reports, but I understand that, in relation to that, there have been no monthly reports since September. Is that the current position? No, the monthly report was published for November. The one for December is due to be published. I think that what may have happened is that the website, what is it called? URL, has changed. Although, if you go on to the old website, it does direct you towards the new one, and on the new one you will find a November report. Okay, that's great. Thank you very much. Within the board performance escalation framework, one board that is not currently in receipt of brokerage, which has identified us potentially in an escalating position, is NHS 4th valley. Given that five boards are at various stages through four or five in the escalation process, I wonder if you could outline what steps are being taken in those boards to ensure that, within the three-year period, they are indeed at breaking. Surely. I know that we are due to send to the committee, and we will do that this week. Clarity on what the escalation levels mean and so on, and the point that I will make before I ask Mr Gray to respond in more detail to your question, is that a board can be at a particular escalation level for one aspect of its performance. It's not always its financial performance, it may be another area of its performance, but we will set that out for the committee when we formally write to you. I will ask Mr Gray to deal with the question that you specifically answered. The committee, from published data, will be aware that NHS 4th valley has struggled for some time to improve its emergency department performance. On that basis, we have put in a support team to the emergency department. The cabinet secretary covered that at the annual review in December, and the chair and the chief executive are fully sighted on what needs to be done. I visited the emergency department over Christmas and New Year to meet them and to meet the support that we are providing so that we ensure that that was working well. That is the basis on which NHS 4th valley at level 3 is not so much connected with its financial position. I welcome what the cabinet secretary said about letting us know the position in relation to escalation. Can the escalation position be included in the monthly monitoring reports in future? Is that something that can be accommodated? Do you mean that, in the monthly financial monitoring report, what level a board might be at? I think that it would be sensible only if it was at a particular level because of its financial performance. Then you are looking at a financial performance and whether or not it is at a particular level. Would that make sense? It is in relation to financial performance that we would be keen to understand what the position is. I want to look at the targets and funding of health boards. Given the fact that our NHS is receiving record additional consequential funding, why the cabinet secretary and the finance secretary have not used that as an opportunity to finally end the underfunding of some of our health boards? Although we have received additional consequential funding and this Government has made up the shortfall, that still means that there are difficult decisions to make. As I said, we will continue to, if I recall correctly, it is £23 million that we are putting into this area to ensure that no board is further away than 0.8 per cent from Enrack funding. When we are in this place next year, we will be continuing to look at what further improvements we can make there, but I think that that is a reasonable position for us to take this year. The budget delivers an under-percentage increase to boards from the overall budget. In my region of Lothian, that equates to £11.6 million less to deliver the same level of services. What impact—in the cabinet secretary and I have had a number of conversations on services being delivered in Lothian, including delayed discharge, where 40 per cent of all delayed discharge in Scotland is here in NHS Lothian—what impact underfunding the health board by £11.6 million do you think that has here in Lothian in being able to meet the targets that you have set for the health board? I need to start out, Mr Briggs, by saying that I do not recognise the numbers that you are talking about at all. The increase to boards in front-line services in this current year was 3.7 per cent in 1920. It will be 4.2 per cent. In addition, as I said out, there is significant additional funds going into the waiting times improvement plan to mental health and, of course, an additional £120 million being transferred from the health budget to integrated services, in addition to the money that health already puts into those services. The issues that you identify quite rightly that need to be addressed in Lothian and elsewhere will be supported by that additional resource, which is in particular an area where the IJAB's work is critical. My understanding of the city of Edinburgh IJAB's work in this area is that it has shown significant recent improvement in reducing the level of delayed discharge. I am happy to send you that information if that would be helpful. I think that both the local authority and the health board recognise a particular additional pressure in Edinburgh in terms of the Edinburgh economy and the level of wages available and the attractiveness of those available. Both the health board and the local authority provided additional funds to allow some of that to be more competitive in that local labour market, which is precisely the kind of flexibility that integration should permit and we should see realised in order to address particular local pressures. I am not making light or in any sense at all, and I know that you understand that, of the particular pressures that are faced in Lothian as elsewhere across the country. There is a core that is the same, there are some differences from one area to another, but my starting point is that I do not recognise those figures that you are using. The figures are in the Government's briefing document, which specifically points towards NHS Lothian being £11.6 million distant from other boards in the funding that is being provided. Obviously being asked to deliver the same, obviously Lothian is also home to a number of national services, so there are additional pressures there as well, but specifically with INRAC targets. Do you, as a Government, still, are you still committed to delivering that parity, which you have outlined? In terms of the services that are also provided here in Lothian, there are additional pressures which are national services, and INRAC funding also takes into account student numbers. Given the growing numbers of students, which is welcome here in Lothian, how do you think INRAC fit for purpose for Lothian and NHS Lothian in the future? Clearly, given that we are now the highest percentage difference and £11.6 million different, are you going to look at this again so that we can actually see NHS Lothian receive its fair funding? NHS Lothian received an adjustment of £7.7 million in terms of INRAC funding. On the overall question of the INRAC formula, a number of different parts of the country would argue that there are ways by which the INRAC formula does not particularly work for them in every respect. I am certainly open to a discussion about the formula as such and whether it continues to be as fit for purpose as we need it to be. However, the formula, like all formulas, is one in which, even if we look to make it as good as we can, taking account of all the differing demands from the Shetlands to Lothian to Dumfries and Galloway, will, nonetheless, as any formula does, produce some who feel that it works better for them than others. We should not set about this discussion thinking that we are going to find a way of reviewing and revising the INRAC formula where everyone is going to be happy at the end of it. However, I do accept that there is more work that needs to be done. I welcome that and I hope that, as a committee, we will be able to look at this further and take that forward. I wanted to shift towards preventative spend within your budget and give you an opportunity to outline how that will be developed in the coming year. Specifically, I wanted to ask, is there additional funds going to be made available for the development of the respiratory action plan, which the Government has outlined that will be published later this year, but there has been no financial commitment to that? So, where we have made commitments to publish plans, for example, on respiratory action plan, then if there are financial requirements as part of that plan, then, yes, it will be funded. There seems to me to be no point in producing an action plan if you do not produce the resources to deliver on that action plan. The review of integration, which has been undertaken by the ministerial strategic group for health and community care, I wonder whether you can tell us when you expect that to be completed and whether it will be made public. I think that Mr Gray is probably best placed to answer that in terms of the timeline, given that he and Sally Loudon from COSLA are the joint chairs of that review. So, the ministerial steering group meets this month towards the end and, convener, I'll provide you the exact date for the sake of not getting it wrong. At that meeting, Sally Loudon and I will present to the ministerial steering group the recommendations that have come from the review that we have carried out. As far as I am aware, the paperwork of the ministerial steering group is in the public domain, so there would be no difficulty whatsoever in sharing not only the recommendations but the views of the MSG with this committee in early course. So, what that should mean, convener, is that at some point I would anticipate before the February recess, I think that that's roundabout the middle of February, we will be able to provide you with the review group's recommendations and the views of the ministerial group and thereafter how we intend, we will follow that through with how we intend to implement those recommendations. Excellent, thank you very much. Can you tell us also in terms of integration authorities when you would expect their budgets for the coming financial year to be finalised? We thought, what, March? Yes. We would expect it to be March. Fine, thank you very much. You will know that one of the things that we focused on in our pre-budget report was the requirement for integration authorities to report budgets against outcomes, and I know that you shared some of the concerns that were expressed by the committee. Do you expect any development on that front in the coming financial year? Mr McCall may want to say a bit more. Our senior finance officials are working with the IJB finance officers to look at how that might be implemented in a bit more detail. I don't know if you want to add to that. One thing that we can say at the moment is that IJBs do publish annual performance reports, and included within that is a financial report. Increasingly, what we're looking to see and the needs need to be published within three months at the end of the financial year, so I think that what we'd be very keen to see on the basis of the current 18-19 financial year is what progress against some of the outcomes that we've talked about, whether that's in mental health or primary care or ADPs, where we're starting to see some things being delivered. I think that those annual performance reports are going to be really key and really crucial as we move forward over the coming years. We also have a finance development group who is looking specifically at some of the more complex finance issues that there are in integration, and we'll be using that group as well to get into how we can budget more effectively to see some of those outcomes being delivered. So, I think that there is scope to see more of that. That's very helpful. We're still, I think, awaiting quarter two of 2018-19 in terms of financial information. I think that it may be a similar problem to the health board information that has been published and the information that is available. I'm interested in set-aside budgets, because previously in the committee I've asked questions and sought clarification on the purpose of set-aside budgets. They're sometimes referred to as unscheduled care budgets, or budgets that are retained by NHS boards for larger hospital sites, which provide integrated and non-integrated services. We took evidence in committee, both oral and written, that said that set-asides are quite working appropriately, as intended, and might even be hindering some integration. So, I'm interested to know if any action could be taken or is intended and being taken to look at set-aside budgets. Do you agree that they might be hindering integration? Or is there a way that set-asides management changes are required? So, I'm familiar with that concern. It has been raised with me by Councillor Corry in COSLA, and there are a number of areas in terms of how the financial position of IJBs operates that we need to consider. We've begun some consideration of that, and that includes what are referred to as set-aside budgets, which are under the remit of the IJB, but I appreciate that, in some circumstances, some IJBs do not feel that they have the degree of commissioning authority over those funds, as they believe they should have. The picture is disparate across the country, as with other matters in terms of integration. I think that what is clear, what is a helpful starting point, is the Audit Scotland report that talks about where leadership is good—to return to Mr Sarwar's point—where leadership works well. We do not see some of the issues around which budget is where, but we see a strong focus on the quality of the service and the appropriateness of the service and how it is delivered in a way that achieves the best outcomes for individuals. What I am keen to do is work with our chief officers and with COSLA, and we have begun that work to try and help all of them to reach the same position where some of the better ones are, both in terms of their outcomes and their approaches used. Part of that will be looking at whether there are mechanisms and levers that we might usefully tweak or move both in terms of set-aside, in terms of what is expected from the funds that go from health, via local government or directly into IJBs, in terms of the outcomes that should be delivered, and also where some of our IJBs have significant levels of un-earmarked reserves and have been carrying those for some time, what might be the most appropriate use of some of that additional resource. We have that discussion begun initially myself and councillor Cary. We will continue that, and we will look to reach some resolution in advance of the 2020 financial year. Good morning, cabinet secretary. On the subject of regional planning, the committee has previously heard concerns over operations of regional planning boards and the way in which it interacts with NHS boards. When will the regional delivery plans be made available? Do you consider whether lines of accountability are to be considered working effectively in the context of integration of health and social care regionalisation? The draft regional plans are currently being discussed with local stakeholders. When that exercise is completed and the return to me with any adjustments or comments required, I will review those and expect to be able to publish them in this financial year, so people are clear about where we are going in the next financial year. On concerns or discussed confusions around accountability, I think that accountability is clear. Health boards are accountable for what they deliver, and IJBs are accountable for what they deliver. The idea of regional working is not new in our health service at all, and what the regional plans are looking to do is to see where we can build on the experience of regional working in previous services to improve the quality of outcomes for patients, either in those services or in other areas. If boards or chief officers require further clarity on accountability, I am very happy to give that, but I think that it is pretty clear. What will be the benefit to NHS of a £700 million investment in social care and integration? That is across the piece in this Parliament widely agreed upon and recognised as the right direction of travel. Our acute hospital setting is absolutely appropriate when there is a clinical need for that, but the majority of people in Scotland—I include myself in that—wants is care and support, both healthcare and social care and support, in my own home or in his homely setting as possible. Shifting the balance of care and integrating health and social care is exactly the right direction of travel. The additional resources that we are putting into that are designed to further support it and drive the pace on it. I think that it is significantly enhanced by the work that is under way in primary care, with a core component of that being the new GP contract and the proposition of GP clusters, of our general practitioners being recognised and given the status that they should have as the expert local clinical lead, the expert clinical generalist, working with a team of multidisciplinary professionals, providing appropriate care for individuals depending on what their particular health need might be. That is a core element of the reform in primary care, and that is a significant driver in terms of integration. At the end of the day, we have touched on it a little bit earlier. One of the fundamental principles behind integration is for the individual who requires and is entitled to and should expect quality health or social care, they really should not be troubled about whose budget it is. They should simply receive the care that we have set out as care that we want to be able to deliver. Questions about accountability, governance and budgets are important, but they are important as the underpinning to that delivery. Of course, we should pay attention to them, but the bottom line is that people should get the care and support that they need and that we have committed to delivering. Emma Harper I want to pick up on David Torrance's question about social care. How much has been invested in the draft budget for free personal care for under 65, so it would be an interesting figure just to get out there? It is £30 million. It is what has been committed in the draft budget. It is clearly vitally important to deliver that for under 65s. We have reached that amount in consultation with COSLA and, based on our estimated figures, and it includes an estimated figure in our work with them about the implementation of that extension of support. I wanted to talk about delayed discharge, a more national picture, because I know that, when the cabinet secretary was appointed, it was something that she specifically set as one of her visions and goals to try to address. Figures out today have shown a 4 per cent increase in November compared to November of 2017, so I wondered in terms of addressing that and where we are currently with the integration of health and social care, are you confident that you will have achieved that in the next two years? Yes, I am. Given that 4 per cent increase, we have seen in one year already. I have only been here for six months. I am not blaming it just on you. It is your 11 years of government, I suppose. In the grand scheme of things, Mr Briggs, I am just starting. I absolutely share your concern about delayed discharge, and I share it because, for the individual who is delayed, that has potentially a significant impact on them. Whether they are frail elderly or not, there is an impact on them as a person, and that is, I know, our shared absolute focus. I am very concerned about delayed discharge and I am concerned about it because I can see in other parts, in some parts of our country, where there is little, if no, delayed discharge. That takes me back to the points that we have touched on earlier in terms of, could we stop talking about sharing good practice and start applying it? That takes me back in terms of our IJBs to the very productive conversations that I have had with Councillor Corry and his colleagues in COSLA about how we use what already is Scottish Government and local authority good practice in the children and young people's collaborative that has produced significant improvements in that area. Can we use that approach, that learning those skills that already exist in both our health service and in local authorities to apply good practice and not simply talk about good practice? I completely accept different local pressures for different IJBs in different parts of the country that we touched on with specific reference to Edinburgh earlier. What I do not accept is that there is significant difference in individual or patient needs that would account for those kinds of differences, nor do I accept that there is significant difference in funding demands or requirements or allocations that would account for those differences. I have little patients with that degree of disparity in delayed discharge figures across Scotland. What I need to do because integration is a joint venture with local authorities is that I need to work with Councillor Corry and we are doing so very productively. With the chief officers, there was a large meeting of chief officers towards the latter end of last year where I made this position very clear. They all applauded, so I presume that they are all agreeing with me, that what we need to do now is actually two years in, begin to apply good practice. There is a minimum that should be required and that is the direction of travel that I am going in. Those who do not agree with you might need to listen to more. I think that that is where we try to move forward health and social care integration. That is really important. There is a political consensus that this is the right direction of travel, but two and a half years into this to see a four percent increase is clearly not going where we all want it to go. I hope in the time that this Government has left for the next two years that we can see where there are opportunities to reform health and social care that you will listen to voices across this Parliament and ideas that parties have been bringing forward to try to tackle this. I totally agree with what you said at the beginning. Those are people's lives and often people's parents and grandparents in hospital when they should not be there and that has to change. You have my absolute assurance that I will listen to ideas regardless of where they come from. In the past two years I have demonstrated that. I am not averse to good ideas where they can be evidenced and where we can show real improvement as a consequence of them. I am very happy to take those on board. I think that your right, in particular, is always worthwhile listening to those who disagree with you to understand the nature of those disagreements. Sometimes disagreements are hyped up as proxies for something else. Sometimes it is about fear of change, sometimes it is about protection of personal status and I understand all of that too. The fact that we have such widespread political consensus for that as the right direction of travel gives us very good grounds to stand on. The work that COSLA is doing with social care providers is another important area in looking at a new national contract and some of the work that we have begun in our discussions with social care and others around the provision of residential care is equally important. We need to be looking at all of that in the round. To pick up on what was said before, I hate to say that the health service has been used as a political tool. It is absolutely wrong and we do agree on the integration of health and social care. I just wanted to ask the cabinet secretary. Dave Torrance mentioned the £700 million that was being put into that, which is good news and I hope that everybody agrees with that. For me, most people here, when I deal with cases, what is happening is that they are discharged because there is not enough care homes to be picked up for elderly people being discharged. I think that that is where the integration of health and social care is so important. It is probably a statement that I am sorry to do, but I get pretty angry when they constantly get attacked and we are moving in that direction and you all said that we are all agreeing that. I just want to ask the cabinet secretary. I know that it is a long-term issue, but would you see improvements in the situation with delayed discharge, particularly with the £700 million that is being put into integration in health and social care? I think that that is an absolute nub of the situation. I absolutely expect to see improvement with that level of investment. If we go back to one of your earlier questions, Ms White was about the balance of allocation to health boards and then what was described as in-year allocations and why I think that that is the right balance to have, because I think that it is very important to focus on in effect, in simple terms, what the money buys and what impact additional resources will have. That is how the budget is framed, if you like. I think that it is interesting the whole question of social care, care homes and care at home. There is some interesting evidence work from social care that points to a changing use of residential care, particularly for elderly with less long-term, more respite, more short-term step-down work from hospitals and so on, and other means by which the care home sector is already changing, but we require to work with them on those changes. There is elsewhere in my portfolio area a major piece of work under way on the reform of adult social care, which is looking in particular less in the area that we are currently talking in, but more in adult social care more widely, where we are looking at individuals with complex health and social care needs, requiring lifetime packages of high intensity and the resourcing to that, and how we might work with local authorities in order to support and improve the availability of those packages by having a different way of approaching the resourcing of those packages. There is a lot of work going on in this area, and I think that the whole area of adult social care is one that is very deserving of a lot of our attention. Thank you very much, cabinet secretary. Almost finally, I think that I have a question around food standard Scotland to whom we heard from in December, and in particular we heard from them about the costs that they faced in dealing with the consequences of preparations for Brexit, which I think that they estimated for the current financial year to be in the region of £1.3 million. The budget includes uplift both from the Scottish Government and UK financed expenditure for food standard Scotland. In your view, do those increases provide sufficient support for further preparations for Brexit, which they may be required to make in the next financial year? I think that the detail behind those increases is in the level four information. I will ask Mr McCallum to just talk through what those increases are for, and I will come back to potential costs of Brexit. There is a £0.7 million funding uplift for Food Standard Scotland in 2019-20, and there are two elements to that budget uplift. One is a technical accounting adjustment that they get funding for impairments and provisions, and that is reflected, and that is about half of that increase. The other half is particularly in relation to animal feed and some specific work that Food Standard Scotland is taking forward in relation to animal feed. There is a budget uplift for FSS, but there is a wider discussion that Food Standard Scotland is having with the Scottish Government about Brexit and the preparations for Brexit. Finally, on that, as members will know from a statement that Mr Russell made most recently in the Parliament, the Scottish Government's resilience group is working now on a weekly basis. That involves key ministers, myself, Mr Ewing and others. It is chaired by the DFM and a large number of officials, looking at what preparations are required to be undertaken in the event of no-deal Brexit, but also in the event of Brexit, in my area, for example, in relation to medicine and medical devices supply and other matters. As we work through the detail of what that is and what we anticipate may be costs, either additional costs or costs that will be incurred in this or the coming financial year that are brought forward costs, we are working with Mr Mackay to try to ensure that we are able to take as many precautions and anticipatory planning decisions on all of that as we can. Thank you very much, cabinet secretary. Clearly, there are important areas of policy that time has simply not permitted us to address in detail this morning. I think of sport of alcohol and drugs of mental health among others. If the cabinet secretary is agreeable, we may drop you a line with those questions and it would be very helpful if it was possible for you to respond to those before we come to the debate in Parliament in two weeks' time. Yes, of course. Thank you very much. Thank you. Thank you very much. We will now conclude the public session of this meeting and we will suspend briefly and then continue in private session. Thank you very much.


Did you know that there are actually three expressions to the gift of speaking in tongues? Here is how I've termed those three expressions. Number one, the personal tongue. Number two, the proof tongue. Number three, the prophetic tongue. Now, though you won't see those exact terms in the Bible, when you study the Scripture, you'll clearly see that there are in fact three expressions to the gift of speaking in tongues. Number one, the personal tongue. The Scripture says, Let love be your highest goal, but you should also desire the special abilities the Spirit gives, especially the ability to prophesy. For if you have the ability to speak in tongues, you will be talking only to God. Since people won't be able to understand you, you will be speaking by the power of the Spirit, but it will all be mysterious. But the one who prophesies strengthens others, encourages them, and comforts them. A person who speaks in tongues is strengthened personally, but one who speaks a word of prophecy strengthens the entire church. That's 1 Corinthians chapter 14 verses 1 through 4. The personal tongue does not benefit others, but that doesn't mean it holds no value. The Bible says a person who speaks in tongues is strengthened personally. The personal tongue is for self edification and it's a heavenly language. Those who use it aren't speaking on earthly dialect. They are speaking mysteries only God can understand them. The personal expression of the gift of tongues strengthens you personally. Number two, the proof tongue. The second expression of the gift of tongues is the proof tongue. Now this is the expression of tongues that is heard as an earthly language. We see an example of this demonstrated in Acts chapter 2. And everyone present was filled with the Holy Spirit and began speaking in other languages as the Holy Spirit gave them this ability. At that time, there were devout Jews from every nation living in Jerusalem. When they heard the noise, everyone came running and they were bewildered to hear their own languages being spoken by the believers. That's Acts chapter 2 verses 4 through 6. Many heard their own languages being spoken by the believers. It was a true miracle. The Holy Spirit supernaturally empowered the believers to be heard speaking in earthly languages that they didn't know. The gift was a sign to the unbelievers thus I call it the proof tongue. Number three, the prophetic tongue. The prophetic tongue is the expression of the gift that's used in the context of a church assembly. The gift, when used, commands the attention of the assembly of believers. Because this expression of the gift can disrupt the flow of a church service if misused, Paul put some regulations on it. Well, my brothers and sisters, let's summarize. When you meet together, one will sing, one will teach. Another will tell some special revelation God has given. One will speak in tongues and another will interpret what is said. But everything that is done must strengthen all of you. No more than two or three should speak in tongues. They must speak one at a time and someone must interpret what they say. But if no one is present who can interpret, they must be silent in your church meeting and speak in tongues to God privately. That's 1st Corinthians chapter 14 verses 26 and 28. Paul the Apostle put restrictions specifically on the prophetic expression of the gift of tongues. The prophetic tongue is meant to be spoken aloud in a gathering of believers. The tongue is then supernaturally interpreted so that the believers present can be helped by the prophetic message. Now allow me to embolden the distinctions between the three different expressions of the gift of tongues. The personal tongue benefits the individual. That's 1st Corinthians 14, 4. The prophetic tongue benefits the church. 1st Corinthians chapter 12 verse 7 and 1st Corinthians chapter 14 verse 26. The proof tongue benefits the unbeliever. 1st Corinthians 14, 22. The personal tongue requires no interpreter or interpretation to be beneficial to the individual. That's 1st Corinthians chapter 14 verse 4. The prophetic tongue requires an interpreter to benefit the church. 1st Corinthians chapter 14 verse 26. The proof tongue requires no interpreter for the interpretation to be understood by the unbeliever. That's Acts chapter 2 verse 8. The personal tongue is understood by no one but God. 1st Corinthians 14, 2. The prophetic tongue is understood by the church with the aid of an interpreter. 1st Corinthians chapter 14 verse 27. The proof tongue is supernaturally understood by the unbeliever. That's Acts chapter 2 verse 8. It's very clear right there in Scripture. One gift, three expressions. Each expression serves a different purpose. I'm David Diga Hernandez and that is Your Moment of Truth. This teaching was taken from my book Praying in the Holy Spirit. If you would like to read the first chapter for free right now, all you have to do is sign up to my emailing list for free. Once you sign up, I'll send you that free chapter download and then every single week I will send you content that will help you to grow spiritually. Go right now to sign up. It's absolutely free DavidHernandezMinistries.com slash email. Thank you for watching EncounterTV. Don't forget to subscribe and click the notification bell. Also, help us spread the gospel of Jesus Christ in the power of the Holy Spirit. Make a one-time donation or become a monthly supporter by clicking on the donate link now.


Hey, welcome to Airman Vision. In today's video, I'm going to be talking to you about the rank structure in the Air Force. Now, before I get into the video, I do need to state that any thoughts and opinions I mentioned are my own, and not that of the Air Force. So with that being said, let's get into the video. So we recreated the BMT memory worksheet that you get at basic training and it is available for download on airmanvision.com and includes things like rank structure, core values, airman song, airman's creed, and other things that you're going to be expected to memorize while you're at basic training. So in this video, I'm not going to explain everything about rank structure because then you would just have to watch the video and write down everything I say. And we actually did all of that for you so you can download the memory worksheet and you have everything right there in front of you. But I will share some tips and tricks that way you can pair the things I tell you with memory worksheet when you have it right in front of you and it's just going to make it a whole lot easier to memorize. So rank structure has two parts. There is rank and there is pay grade. Rank is going to be the name and pay grade is going to be E1 through E9 or 01 through 010. A lot of times people use these interchangeably so you can use either one of those. So on top of knowing the rank and the pay grade, you're also going to have to know the insignia which is the emblem, the shape of whatever that pay grade is. So some tips for the enlisted rank structure is the pay grade is one more than the amount of stripes that the chevron has in the insignia. So for example an E3 is a chevron of two stripes and E9 is a chevron of eight stripes and that is an easy way that you can remember those. Some tips for learning officer ranks. First I'm going to talk to you about the lieutenants. So the first rank in the officer rank structure is a second lieutenant and then the next one is a first lieutenant. That may seem a little confusing because second comes before first but just think of it this way. Second lieutenant gets promoted to first lieutenant and that was an easy way to remember that. The next one is going to be learning the insignia for colonel which is a silver spread eagle and I actually got this information from Johnna Logic. She's a super sweet youtuber and whenever she said this like it just clicked for me. There are different things that work for different people and I'm kind of weird about the way that I learn and memorize things but I absolutely love the way she explained this. So the rank is a colonel and the insignia is a silver spread eagle and she said the eagle looks like a chicken and colonel sanders makes chicken and I was like oh my gosh I love that. So anytime I heard colonel I automatically went to chicken and then I was like well that's a silver spread eagle easy. So the next tip is going to be for the generals which is going to be an 07 through 010. The insignia is being one star two star three star four star but if they're all generals how do you remember the names and which order they go in it's brigadier general major general lieutenant general and general. So an easy way to memorize this is to learn the phrase be my little general. Be is brigadier my is major little is lieutenant and general is general. So if you learn that phrase it will help you learn the order that the generals go in. We also have workout programs to help you prepare for PT before getting to BMT. Tons of information about BMT, tech school, ASVAB requirements, job information and all sorts of things like that. Hopefully this video helped you. Be sure to subscribe for more Air Force information and I will see you guys in another video.


We're here today in Sanford Fleming Elementary School in the southeast of Vancouver. We're here in the old building and we're here to announce the very exciting news that nineteen point six million dollars is now committed from the seismic upgrade program to build a brand new school. The additional piece of it of course is the partnership with the city of Vancouver which puts a childcare on the third floor of the building so parents can have the convenience of having very very young children in the same building as their elementary school kids. There's going to be a place for my mom or dad to drop off my little sister because usually then she has to ask my my aunt or somebody to come and take care of her. Now we're at the beginning of the last stage and the last stage is the most exciting stage for us. It's the building of the moving into a brand new modern beautiful facility for our learning community so that's great. It's a beautiful structure, lovely new school and an important safety improvement, vast safety improvement for the kids in this school so we're very pleased to be here making that announcement.


A great season came to an end for the Bemidji Girls Tennis Team last week. The Lumberjacks went 18-3 on the season but fell to brainered in the 8-AA subsection tournament. The season continues though for number one singles player Abbey Kelm. Kelm went undefeated in 26 matches this season and rolled through the single side of the bracket on her way to a subsection championship. Now, she'll look to continue her success this weekend. I'm really focusing a lot better this year I feel like, especially last weekend it's actually a lot better this weekend. I feel like it was a lot better than the year before. She's been prepping for this, you know, post-season all season now. I think the mentality knowing this is what she was going to do helped her focus just on singles. I think if I can keep playing like this, I'll do great. And it's not like I'm not too concerned like how everything, I just hope I play good. And if I play good, I'm satisfied. And the other Lumberjack joining Kelm will be junior Laura Palmer. Palmer finished third in last week's 8-AA subsection singles tournament. And the other Lumberjack joining Kelm will be junior Laura Palmer. Palmer finished third in last week's 8-AA subsection singles tournament. And after a strong season, she will be making her first section tournament appearance. I'm just trying to play my best and just see how it goes first time. So just kind of trying my best and doing the best I can do. When we get down to this tournament, I think, you know, she's a player that would be easy to overlook. And that would probably be a mistake right now. She's playing well. And Abby Kellin will face Kate Inderiden from St. Cloud Tech this weekend. And Laura Palmer will take on Kill Hovland out of Wilmer. Both those matches starting at 9 o'clock tomorrow morning over in Fargo. And the unfortunate thing, though, is if both of them win, they'd have to face each other right away in that second round. So three matches total, though, if they can make it tomorrow. And hopefully we see a winner from one of those two. Absolutely. Already ball tournament time. Yeah, it's hard to believe it's that time of the year for us. If you've enjoyed this segment of Lakeland News, please consider making a tax deductible contribution to Lakeland Public Television.


Cankersores can be a painful, recurring inflammatory process of the lining of our mouths, and similar to other chronic inflammatory conditions, DNA damage due to oxidative stress-free radicals is thought to play a role. Normally, free radical production is balanced with antioxidants. However, if the free radical concentration gets too high and our antioxidant enzymes and the antioxidants we get in our diet cannot adequately compensate for these radicals, the balance is shifted in a pro-oxidant direction, which can lead to oxidative damage within our body. OK, so do those with recurring kankersores have fewer antioxidants, more oxidation and more DNA damage? Yes, yes, and yes, more pro-oxidants and more oxidative stress in their bloodstream, lower antioxidant status and more DNA damage, suggesting it might be possible for antioxidants to help, but you don't know until you put it to the test. 16 boys and girls around age 12 with recurring kankersores, given a whopping 2 grams of vitamin C a day. That's considered the tolerable upper-daily limit for adults before you start getting diarrhea, and 1200 milligrams may do that in a 12-year-old. But it's all about risks and benefits. How did they do? 15 out of 16 caught the number of kankersores they were getting at least in half. In three months before they started the vitamin C, they averaged four kankersores, but in three months they were on it, had less than one on average. Then they tried stopping the sea for another three months, and the ulcers started coming back, and so they added the sea back, and the kankersore rate dropped again. What about applying antioxidants directly? Like a turmeric gel containing 2% curcumin, the yellow pigment of the spiced turmeric, swamped directly onto the kankersores twice a day. It did seem to significantly reduce pain intensity and ulcer size compared to placebo, compared to a gel containing no active ingredient, but it would be nice to see a comparison to some active treatment and from an independent research group, not funded by the curcumin gel manufacturer. And here it is, a randomized clinical trial, a generic 2% curcumin gel versus a prescription steroid gel, and their curcumin worked just as well, providing strong evidence that can be used as an effective and safer alternative to steroids for the treatment of recurring kankersores. But if you remember, topical honey beat out the same steroid for both ulcer healing compared to the steroid, and pain reduction compared to the steroid. So if you're going to use something topically, honey seems best, but what if you just want to swallow something instead, it's something that doesn't give you diarrhea. 31 patients with recurring kankersores were split up into two groups, getting either 20 milligrams of yeast-beta-glucan fiber a day or placebo. That's the amount found in just an eighth of a teaspoon of brewer's yeast or nutritional yeast. In the placebo group, no significant change, whereas in the yeast group, ulcer severity was cut nearly in half. So that's something else you can try. If it's an antioxidant thing, can you just eat a plant-based diet, lots of fruits and vegetables, and treat it that way? That's never been put to the test, though a plant-based diet could also make things worse if one is not ensuring a regular, reliable source of vitamin B12 through supplements or fortified foods. For example, 30-year-old woman with four years of recurring kankersores, eating so few animal products and no supplementation, she became vitamin B12 deficient. And it started feeling weak and tired, numbness and tingling. So they immediately started her on B12, and thankfully her B12 deficiency symptoms got better, but so did her kankersores, a rapid and complete recovery within weeks of starting B12 after years of suffering. We've known B12 deficiency could lead to kankersores since the 70s, so much so that a recommendation has been made to consider B12 deficiency any time you see a patient with recurring kankersores. In fact, a number of nutrient deficiencies may do it. If you compare the lab tests of those with recurrent kankersores to those without, more than half of the kankersore group showed evidence of hematonic deficiencies, in other words, blood-forming nutrient deficiencies compared to less than 1 in 10 in the non-kankersore group. So we're talking like iron deficiency and folate deficiency in addition to B12 deficiency. So they gave them supplements, and their kankersores improved, especially among those who didn't have a family history of kankersore problems. OK, so you could see how vitamin and mineral supplements might help people who are deficient, but might a supplement like vitamin B12 help even people not B12 deficient? Apparently so. As the title says, cyanocobalamin, the most common form of submental B12, may be beneficial in the treatment of recurrent kankersores even when vitamin B12 levels are normal. They took a group of 72 patients with frequent kankersores and gave them B12, regardless of what their levels were, and in 96% of cases, they got better. And that was among both those who started out deficient and those who started out with regular B12 levels in their blood. But there was no control group, so you don't know how many would have gotten better anyway. And they injected the B12, and injections can have an even greater placebo effect than pills, especially perhaps with something like B12, which has a striking mad scientist looking ruby red color in the syringe. But there had never been a randomized, double-blind, placebo-controlled trial of oral B12 for kankersores until there was 1,000 micrograms of sublingual B12 a day for six months. And it took five months, but eventually the duration of kanker outbreaks, the number of ulcers in the level of pain were significantly reduced. And again, regardless of the initial vitamin B12 levels in their blood. So B12 deficient or not, vitamin B12 supplements seemed to help. By the end of the study, twice as many in the B12 group appeared to have been cured. So vitamin B12 supplements represent a simple, inexpensive, low-risk, effective treatment, though it appeared to take months before it starts working. Whereas if you apply B12 directly to the kanker store, a randomized, double-blind, placebo-controlled trial of a B12 ointment applied directly to the kankersores, you can get at least significant reduction in pain within two days, compared to placebo. And again, it doesn't matter whether your vitamin B12 deficient or not.