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I will hand over to the CMO shortly for him to add his clinical expertise, but it is fair to say that they are well understood. One of the most difficult decisions that was taken during the pandemic was the decision to pause elective care, and there is no doubt about the effect of that. If someone is on a waiting list, the effect of cancellation is not benign. People deteriorate and decondition. We are seeing people present sicker and with higher acuity, and that deterioration and deconditioning are contributing factors to that.

I regularly speak to orthopaedic surgeons in particular and to the Scottish collaborative orthopaedic trainee research network—SCOTnet, as it is known—and they often tell me that there is no doubt that given the difficult but, I would say, necessary decisions that were taken during the pandemic, people on waiting lists are deteriorating and deconditioning, particularly if they are on long waiting lists. That is why, when I announced certain targets in the summer, the focus was on those long waits, because we know that people who wait for excessively long times for elective care will come to harm. There is no argument from me on that. My goodness—when we speak to people who suffer with chronic pain, we can really understand from their perspective how detrimental that is to them, and I will not pretend otherwise.

In the context of the winter pressures, Evelyn Tweed will be aware that three health boards have taken the decision to have a time-limited pause on elective care. I stress the term “time-limited” because, although those are local decisions, I have made it clear to those health boards—they understand this and there is certainly no argument from them on it—that the measure should be in place for as little time as possible, given all the impacts that pausing elective care can have.

That is also one of the reasons why we did not move the entire NHS to an emergency footing during the winter. Some people called for us to do that, and I understand where those calls came from. However, if we had moved the NHS to an emergency footing, as we did during the early days of the pandemic, instead of three health boards pausing elective care, all 14 territorial boards would potentially have done that. That would have had a severe impact on people up and down the country.

Please forgive me for again giving a fairly long answer to a short question, but I hope that that gives you an understanding of the situation. I will bring in Dr Smith.

I referred to the RCN round table that Gillian Mackay and I both attended. I will not reiterate everything that I have said about the retire-and-return policy, but I am happy to provide more detail to the convener, who could share it with committee members.

First, that policy came as a direct result of our hearing nurses in particular say that, after 20, 30 or 40 years in the profession, they were thinking of leaving because of the inflexibility around the possibility of retirement and return. Many of them just wanted to reduce their shifts, but the inflexibility of the system did not allow them to do so.

Secondly, it is worth reiterating the obvious point that one of the most significant things that we can do to try to retain our workforce is to reduce workload pressure. All of us round the table have spoken to NHS staff, and whether they are nursing, medical or midwifery staff, they always use the word “relentless” to describe the past three years. They have often told me that in a typical NHS career in a hospital—the same thing happens in community, primary and secondary care—they gear themselves up for the winter, during which they know that they will have a rough few months, then the pressure begins to ease, and they then gear themselves up once more as we get towards winter again. In effect, however, that has not happened for three years: there has just been relentless pressure.

Notwithstanding how difficult the past few weeks have been, the work that we are doing to try to reduce workload pressure means that, although it will not be easy, we will begin to see an easing of the most extreme pressure that we have seen throughout the winter. The question is what we can do to try to stabilise the service so that it does not feel as relentless as it has felt in recent months and years.

Pay is important. We cannot skirt that issue. Ensuring that people who work in our NHS and indeed in social care are appropriately rewarded is really important. I will not rehearse again everything that I have already said on that, but we have a fair pay offer on the table. Gillian Mackay will know that, at the end of last week, we came to an agreement with the three trade unions that were in dispute and had a strike mandate that they will pause strike action, and we will enter negotiations on 2023-24 pay this week.

Pensions are really important, too. The point on the disincentive around pensions comes up regularly, particularly from the medical workforce. I will not rehearse again what I have already said, but the Government can take and has taken action in relation to the BMA wanting to go further with pensions.

That is important in a rural setting. It is important everywhere, but the real advantage of a rural setting is the improved work-life balance that attracts people to work there. For retention purposes, we have to work and are working across Government and across portfolios to deal with housing, education and later-life provision for people, all of which has to form a holistic package.

Again, please forgive me for giving a long answer. I think that Sir Lewis wants to comment.

First, there is no doubt that the feedback overwhelmingly suggests that, if we can train people locally, there is a better chance of retaining them locally.

I will not rehearse what has already been said about the ScotGEM programme, but our GP fill rate for that in the north of Scotland is exceptionally good. I have mentioned the shortened midwifery course, which involves distance learning so that people can stay in their localities while they study and train to become midwives. We are already doing a lot in that space.

I have said to health boards that they should be as innovative as possible. We are looking at how many of the additional training places that we have made available for the medical workforce can be filled by those from remote, rural and island health boards.

For the sake of brevity, it is worth saying that there is no doubting the premise of Carol Mochan’s question. A fair bit of work is going into making sure that we have as many training places as possible in remote, rural and island Scotland, whether those are for nursing, midwifery, GPs or other parts of the medical workforce.

I know that we are tight for time, but Sir Lewis Ritchie probably has the necessary expertise to comment on that.

I cannot put a figure on that just now. There are a number of drivers for looking at the use of digital, as well as other reforms to the NHS. One is the demand on services across the country. There is no getting away from the fact that, whether in primary or secondary care, people are presenting as sicker and with higher acuity levels. That is due to the pressure that the pandemic brought to bear and the fact that people were not able to access services, particularly at the beginning of the pandemic, as a result of the really difficult choices that we had to make to suspend or halt services such as screening.

One reason for reform and innovation is the demand that the system faces and will face in future years. The other is cost. We absolutely have to look at the fact that our health service now costs the Scottish Government £19 billion, which is a significant investment. Obviously, that investment in the health service will continue but, as others have said, simply putting more money into the health service will not necessarily help us to improve services. Although that investment will certainly help, innovation has to be key, and digital has to be part of that.

The BMA is among those calling for, as it puts it, a “national conversation” around the NHS. Whether we have a national conversation or call it something else, there is absolutely space to have a conversation with the public about how they want their health service to respond to their needs in the future and what kind of reform they want to see. I make it absolutely clear that reform should always be within the founding principles of the NHS—there should be no ifs, buts or maybes about that—but discussions about reform and innovation are crucial.

That is a good question. It is really hard to say, because it is difficult to determine the number of patients with Covid and the number who are in hospital because of Covid. Given where we are with community-wide testing, the question is probably near impossible to answer definitively.

However, we have to get to a stage—it is right that we do—where we treat Covid as we treat flu and other such viral infections. I understand people’s concerns about that, particularly the concerns of those who care for somebody who is vulnerable or those who are themselves vulnerable or immunocompromised. I completely understand the nervousness that they have been expressing from the moment we began to reduce community testing. Essentially, as Emma Harper’s questions alluded to, we do not have the funding from the UK Government to continue that testing, so we have to get to a space where we treat Covid as we treat other viral infections of that nature.

We have not yet defined the timescale for exactly the reasons pointed out by the individual who contacted you. There are some real complexities that we have to work through. Employers are committed to sitting down with trade unions as soon as possible to work through the detail of those. Once we have the timescales, we will be open and transparent, and we will make them public.

Thank you for the question. There is no doubt that NHS 24 is an absolutely vital service. It is critical to us. It has been an extremely successful service since its inception. NHS 24 has exceptional levels of data, as you can imagine, including call data, call-waiting data, data on how many people are triaged and data on how many people are recommended for transfer to A and E. It is very clear from the data that the overwhelming majority do not need onward transfer to A and E. I therefore see NHS 24 as being critical in trying to reduce that demand to the front door. The thinking is that the more that we can bolster staffing levels with call handlers and clinical staff, the better, and we have increased the number of clinical staff quite significantly. If I look at figures from September 2021 to September 2022, I can see that the real increase in clinical nursing staff has helped with that.

The reason why you will see funding as it is for NHS 24 is that there is definitely more that we can do on the digital offer. NHS 24 has launched an app, which you can download whether you are on Google or Apple. It has self-help guides and provides a great service whereby you can view the pharmacy, general practitioner services and other primary care services that are local to you and what their opening times are. It is a minimum viable product at the moment, as it has just launched, but it will grow arms and legs as time goes on, and some of the funding in the budget will help us to do that. In short, a lot of the focus will be on staffing and the digital offer.

That is a good question and one that we anticipated coming up, because members of Parliament are right to ask for that clarity on the national care service. If you look at our current financial memorandum for the NCS, you will see that we talk about the figure for the coming financial year being around the £63 million to £95 million mark. You will also probably be aware that the Finance and Public Administration Committee has come back to the Government to say that it wants a revised financial memorandum. There has been a fair degree of scrutiny. Richard will correct me if I am wrong, but I think that we said that, once we have the draft of the revised financial memorandum, on which we are working, we propose to come back next month to the committee with it. It will lay out in detail how much we will be spending specifically on the national care service. It is therefore work that is under way, given that we have been asked to provide a revised financial memorandum.

I can certainly write to you. Forgive me; I am just checking, but I do not think that I have quite that level of detail. It was not just NHS 24, of course; there was redeployment to NHS boards, territorial as well as non-territorial. Forgive me; I do not have that detail to hand, but I am more than happy to write to the convener, who can share it with the rest of the committee.

There is no doubt that there are impacts on budgets and therefore on the ability to be innovative, whether with the estate or otherwise, in trying to mitigate those impacts. You will know from the 2023-24 budget that we have increased funding to boards by just under 6 per cent, which is a significant increase. I should have said from the offset that the health and social care portfolio is getting an additional £1 billion. I hope that that is a demonstration of how much the Government values our national health service, and it is more than the consequentials that we received. However, all that being said, inflationary costs are putting real pressure on us.

We are investing in a number of capital projects. It is important to say that there are also significant refurbishments—and not just normal maintenance refurbishment, although that is very important, of course, as a number of health boards are also looking at how they can make their buildings more carbon efficient in line with our net zero targets and our net zero health plan. That work does not come without an up-front capital cost, and we are very mindful of that. The net zero agenda has always been incredibly important. It has even greater importance, given the eventual savings that could be seen in energy costs in the future, although it involves up-front costs.