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There are a number of different ways in which we try to invest through preventative spend. It is normally around behavioural change programmes on things such as alcohol and drug use, eating habits and smoking. All of that work is about prevention and trying to reduce the health consequences that we experience as a result of those challenges. Much of that work is done through marketing campaigns and service delivery programmes, for which we fund the NHS boards. Many programmes will have targets. For example, smoking cessation programmes have a target for the number of people that they help to stop smoking. We are therefore able to monitor the progress that boards make against such targets.

We invest in a number of areas. For example, we are taking forward some innovations around type 2 diabetes remission, type 2 diabetes prevention programmes, the digital dermatology programme, vaccination programmes and artificial intelligence for lung cancer. We use all those programmes to help to do more in the preventative space through the use of innovation.

How have we identified some of the things that we have taken forward? We have a programme called the accelerated national innovation adoption pathway, which is run in partnership with the chief scientist office to identify areas for investment in preventative spend and things that we know will have a significant impact in improving outcomes. We use a once for Scotland approach to identify the most appropriate areas for investment in new technologies in NHS Scotland to support preventative spend.

We can evaluate those programmes as they are rolled out and as those investments are made. With the combination of programmes that we run and evaluate through health boards for preventative healthcare issues and the ANIA programme, we target innovations that we know can help to prevent ill health and improve outcomes for individuals, and we assess the most effective routes for making the investments and evaluating their impact.

The fact is that it is very often the NHS that has to deal with the consequences of lifestyles that result in ill health, but other services could do more to prevent such issues from arising. As the evidence shows, the investment that we are making in areas such as the early years is critical in helping to improve outcomes for children and young people. We have seen internationally that early years intervention is much more effective in helping to improve outcomes not just for children but later in life, too.

Our investment in approaches to tackling child poverty, such as the Scottish child payment, will help to reduce some of the risks that are associated with child poverty, which can have an impact on an individual’s health and their long-term wellbeing. There is also the best start programme. Those measures, some of which are health related and some of which sit in other portfolio areas, can have an impact in helping to improve health outcomes.

If we look at the disease tree of obesity and all the different branches that come off it, from cardiovascular and respiratory issues to diabetes and all its consequent issues, including neuropathy and so on, we can see that, if we tackle some of the root areas more effectively, we will head off some of the other health complications that are consequent to the condition. As I suspect you recognise, tackling obesity is critical to helping to reduce demand on cardiovascular, diabetes and some respiratory services and everything that goes with that, and doing so would have a preventative benefit in the future.

That said, the biggest risk that we have in tackling these challenges, particularly the health inequalities that we are experiencing, is that two key areas are moving in the wrong direction. Mortality rates are increasing and health inequalities are widening—as they have been for more than a decade now, largely as a result of austerity. All the evidence demonstrates that, as the social protection system is reduced, the impact that that has in increasing mortality rates and inequalities gets greater. We have been going through that in the past 10 years, which is why that data is going in the wrong direction.

There are certain things that we can do to try to mitigate some of that, but it is clear to me that the austerity that we have had for more than 10 years and the austerity that we are experiencing at an even greater level just now will result in people dying prematurely because of the impact that it has on the social protections that people depend on. It is probably one of the biggest public health challenges that we face going forward. If there is one thing that I would do to tackle health inequalities and their consequent problems, it is to tackle the economic policy around austerity. That would have the biggest impact in helping to reduce some of the very marked inequalities that have been expanding in recent years.

I am more than happy to ask the justice secretary to respond to the issues that you have raised, given that it is a justice-led area rather than a health-specific area.

We made a commitment to invest an extra £250 million in the twin areas of drug and alcohol services over the course of this parliamentary session and we are on track to achieve that. That is an increase in investment over the past couple of years and we want to ensure that we continue to make progress with that.

It is down to local partners to determine how they think that funding should best be delivered at a local level. Some of the services that might operate around alcohol and drugs issues are not funded directly by the health portfolio—they sit in other portfolio areas. I am more than happy to ask the justice secretary to respond to the concern that you have raised about the 218 service.

This statutory instrument is first and foremost about patient safety. Safe, effective and person-centred practice is the driving force behind how we deliver healthcare in Scotland and patients have a right to know that they are being cared for by professionals with the appropriate level of assurance and accountability.

People in the roles concerned have been practising across the UK for 20 years now and we cannot delay regulation any longer. With numbers and skills continuing to grow, we must introduce consistent UK-wide standards that are supported by meaningful sanctions when they are not met.

The instrument is also a significant stride along the road to meaningful reform of the regulation of health professionals, which I know several members around the table today will appreciate.

In bringing these devolved professions into statutory regulation, the order also brings the General Medical Council within the competence of the Parliament, and therefore this committee, for the first time. The regulatory landscape is complex and unwieldy, with each regulator operating within its own legislative framework. There is too much inconsistency and bureaucracy, which restricts the ability to swiftly adapt to the evolving demands on our health services without recourse to legislation.

The order is the culmination of years of collaborative working between the four Governments of the United Kingdom and multiple public consultations. As such, it is the first step towards a more modern and flexible model of regulation, establishing the first generation of a framework that will ultimately apply consistently across the health professions.

The order requires the GMC to set up a register and to put in place processes around education and training, fitness to practise, offences and appeals for the roles concerned. I must acknowledge the pejorative commentary around those roles in recent weeks, across both social and mainstream media. That relentless negativity has been detrimental to our physician associates and anaesthesia associates and I hope that this statutory regulation will promote respect for their contribution to our healthcare system. It is important to note that, although each of the Governments agrees that regulation is necessary, decisions on the utilisation of the roles in NHS Scotland will be taken by the Scottish ministers, based on what is best for the people of Scotland.

Our wider approach to the development of the workforce will be informed by our newly established medical associate professions—MAPs—implementation programme and overseen by a programme board that is made up of a range of key partners. We expect the board to meet for the first time next month.

I am of course happy to respond to any questions that the committee may have.

I mentioned that in my opening comments. We have set up the medical associate professions implementation programme, which has a board that includes key partners from NHS Scotland and the royal colleges. The purpose of that programme is to ensure that, going forward, we have a clear implementation process for PAs and AAs as regulated professionals and how they will be deployed and used in NHS Scotland.

I have also set out clearly to the BMA the difference between the approach that we are taking and that of the UK Government. Many of the BMA’s concerns relate to the way in which the UK Government has dealt with the regulation of PAs and AAs and how it has set that out in its workforce plan, which has conflated two issues. We are taking a different approach in Scotland: it will be much more evidence based and managed and those roles and the way in which they will be used in NHS Scotland will be clearly defined.

I disagree with that, and it would be unfair to suggest that waiting times for CAMHS have not been reduced. There has been a very significant reduction in waiting times for CAMHS, and in particular of the build-up that developed over the course of the pandemic. Staff across our child and adolescent mental health services are working really hard to address the waits, and we have seen very significant reductions in them. Of course, where there continue to be extended waits, that is not acceptable, and that is why work is still being undertaken to address the issue.

However, anyone who looks at the course of the mental health budget over the past couple of years cannot avoid seeing that the budget has, in some cases, more than doubled. That has allowed for a significant expansion of services and an increase in capacity of those services, which we are now seeing the benefits of in terms of the waiting-time reductions that we are achieving in CAMHS services overall.

I recognise that challenges remain in delivery of mental health services. Notwithstanding that, very good progress is being made, and the sustained increase in investment that we have made over the past couple of years is making a difference.

Let us look at where we are with A and E at present. We have seen an improvement this year compared with where we were last year. We are continuing to work with health boards to sustain further improvements.

You will be aware that one of the major challenges that we have with A and E performance is flow from A and E into hospitals. A significant part of that is caused by delayed discharge. Despite the fact that around 98 per cent of all discharges from hospital take place on time, the 2 per cent that do not have a significant impact on flow into hospitals from our A and E departments. This year, we saw a reduction in the number of delayed discharges compared with where we were last year. I want to ensure that we do intense work this year on what more we can do to reduce delayed discharge, because we know that that is critical in supporting the flow into our hospitals.

We are doing a second element of work on reducing the level of demand at our A and E departments. For example, the work that the Scottish Ambulance Service is doing through its integrated clinical hub is reducing the number of people who have to be conveyed to our A and E departments, and that is as a result of the investment that we are making into that service.

We are doing work to improve those things, but demand is significant. I believe that we can still make further progress, and I am determined to ensure that we do that during the next year. We will continue to focus on the areas that we know will improve the performance that we get in our A and E departments and across our unscheduled healthcare system. We are making progress, but there is certainly much more to do, and there is determination to ensure that we do it.

We have, I think, five health boards at stage 3 of the escalation process. It is important to emphasise that providing tailored support to boards that are experiencing specific financial pressures is not new. The mechanism has been in place and has been used at various points over the years. Clearly, though, we are in a very challenging financial environment, so we have boards that are under extra pressure.

I will get Richard McCallum to say a bit more on a couple of areas that he has just touched on. One area is how boards manage their staffing. There is the use of agency staff versus bank staff and the issue of recruiting staff. The second area is prescribing. There are marked variations among boards in prescribing and in the costs associated with it. Although we might procure a lot of the drugs in Scotland centrally, prescribing variations can have an impact. The chief pharmaceutical officer is doing work to ensure that we do as much as we can to get greater consistency in prescribing, because that can also address issues around the costs associated with prescribing.

Richard, do you want to say a bit more on some of the other work that we are taking forward to give support around financial sustainability?

There was a consultation exercise, part of which was about which regulatory body would be most appropriate for the regulation of PAs and AAs. A significant majority of respondents—just under 60 per cent, if I recall correctly—to the consultation said that the GMC would be the most appropriate body to carry out that regulatory function. The order, and the approach that both the Scottish and UK Governments have taken, reflects the feedback from that consultation exercise.

We gave a commitment to increase investment to some £250 million during the parliamentary session to tackle the twin challenges of drug and alcohol misuse, and we are on track to deliver that and sustain that level of investment.

We are keen to see further growth in the provision of rehabilitation services, and work has been done to achieve that. The commitment that we made to ensure that there was sustained investment in drug and alcohol services is being taken forward in this budget so that we continue to see the progress that we need in the delivery of those services to improve outcomes for those who suffer from drug and alcohol misuse.

Funding for the drugs policy has increased by 67 per cent since 2014-15. There has been a sustained period of increased investment. We committed to ensuring that there was additional investment of £250 million to support our drugs and alcohol mission, and the budget builds on delivering that.