Health and Sport Committee

Meeting date: Tuesday, September 27, 2016

Official Report 548KB pdf

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General Practitioners and GP Hubs

We now welcome to the meeting Shona Robison, the Cabinet Secretary for Health and Sport, and from the Scottish Government we welcome Richard Foggo, deputy director in primary care, Gregor Smith, deputy chief medical officer, and Shirley Rogers, director for health workforce. I invite the cabinet secretary to make an opening statement.

Thank you very much, convener. I have provided the committee with a written update on the significant progress that we have already made and our next steps in supporting general practice and transforming primary care.

It is fair to say—I have said it before—that general practice is at the very heart of our NHS. With over 90 per cent of healthcare being delivered in primary care and more than 24 million consultations in general practice every year, we must ensure that Scotland’s GPs get the support that they need in order to flourish.

However, we know that, as you have heard, general practice is under significant pressure. The scale and nature of demand are changing, with an ageing population, increasing complexity and the continued impact of health inequalities. To meet such challenges, we cannot continue to look back; instead, we have to focus on a vision for the future.

Last December, therefore, I set out in Parliament my vision for a community health service that is at the heart of Scotland’s NHS. In that vision, a wider range of services would be provided by a wider group of highly skilled professionals, who would work as integrated teams and deliver care in and out of hours, tailored to local needs. Scotland’s GPs would provide leadership within those teams, and there would be an enhanced leadership role for Scotland’s nurses, pharmacists, paramedics and other allied health professionals.

In my written update, I have set out the outcomes and actions that will deliver that vision. We have increased investment in our primary care fund to £85 million over three years. To ensure that that investment makes a difference, we are testing new models of care in every health board area, with a focus on improving primary care mental health and out-of-hours services. More than 80 tests of the new model are already under way.

We have also committed to increasing the share of NHS funding for primary care year on year throughout this session of Parliament. As investment grows, we will use it to support local areas in rolling out the most successful tests. That is a measured and evidenced approach to change. After all, if the future of primary care is multidisciplinary, the bulk of our investment should be in the primary care workforce.

Of course, we have already taken a number of actions. We have increased GP training places from 300 to 400 per year, we have invested £2 million in GP recruitment and retention, including for a rural medicine collaborative and the deep-end practices, and we have committed more than £16 million to recruiting 140 whole-time-equivalent pharmacists in general practices. Moreover, in the programme for government, we have committed to increasing the numbers of GPs and nurses who work in our communities. We are recruiting 250 community link workers to work with GPs in the most deprived communities, and we will over the next five years train an additional 1,000 paramedics to work in community settings.

I think that that is the basis of long-term change, but we know that general practice faces pressures in the short term. That is why, in March, I committed an additional £20 million for immediate support to GPs and their practice staff. That money provided an uplift in GP pay and expenses, supported the introduction of GP clusters, introduced occupational health cover for GPs and ensured fair parental-leave arrangements for GPs. All those issues and priorities were raised by the profession itself.

The longer-term changes that we seek cannot be delivered through the GP contract alone, as they require changes to the wider workforce and infrastructure, but we are working effectively with the British Medical Association to deliver a new GP contract from 2017. That collaboration has already allowed us to abolish the bureaucratic quality and outcomes framework and to introduce GP clusters.

I know that everyone around the table is committed to the future of general practice in Scotland. We recognise the challenges, but I am ambitious for the future of general practice and primary care, so I welcome this opportunity to discuss the plans with the committee.

Thank you, cabinet secretary. We now move to questions.

I thank you, convener, and I thank the cabinet secretary and the rest of the panel for joining us this morning.

In the previous evidence session, we had a protracted discussion on how the situation with workforce planning, particularly in the GP sector, might be characterised. I am very keen to hear from each of the panellists individually on whether they would characterise our current situation as a crisis. After all, although more training places are being made available, they are not being filled, and when they are filled, they are not always being filled by Scotland-domiciled people. Despite the fact that there might have been an uplift in headcount in the GP profession, we are actually seeing a drop-off in full-time-equivalent posts, to the extent that we might by the end of the decade have as many as 900 fewer GPs than will be required. Is that a crisis?

It is, without a doubt, a challenging situation—I have never shied away from saying so—which is why I have, since I became cabinet secretary, spent a lot of my time looking at the future of primary care and its importance in helping us to develop a sustainable NHS. In fact, I have probably spent more time on that than on any other issue. If I had not recognised that there was a challenge, I would not be doing that.

We have also engaged very effectively with stakeholders in discussing solutions to the challenges, but there is no single quick fix. We have already accepted that we need more GPs; however, this is about not just the number of GPs, but what those GPs do. That is why the new GP contract is so important; it seeks to support new models of working, including multidisciplinary models that utilise the skills and abilities of other staff to ensure that we can get a sustainable model of primary care.

As I have said, I have never shied away from making clear the scale of the challenge, but the more important issue is what we will do about it. On Scotland-domiciled students, which Alex Cole-Hamilton mentioned, we have taken a number of actions. We are from this year onwards increasing by 50 the number of undergraduate medical places, and we have been very clear with universities that we want the widening access agenda to feature very strongly in respect of those additional places. Moreover, we are well along the way with our plans for a new graduate medical school, which will have a very clear focus on primary care and rurality.

We are also looking at ways of linking the payment of graduate fees with a commitment to working within our NHS—the most important thing is to keep doctors who train here working in our NHS. There are many who are not Scotland-domiciled who have trained here and have worked here for long periods of time—we want more of them to choose general practice over other specialties. That is one of the challenges; again, I say that we have been working with the medical schools on how we can make general practice more attractive. We have also increased the number of training places and are providing some interesting and different opportunities through, for example, the GP fellowship scheme—which is attracting quite a lot of interest—and bursaries.

We have looked at a wide range of mechanisms to get more young people to go into medicine, choose general practice and stay working here in Scotland. The graduate programme will encourage a wider variety of people of all ages and from all backgrounds to go into medicine, which will be good for the medical workforce in Scotland.

I do not doubt for a minute the sincerity with which you are approaching the problem, but would you characterise it as a crisis?

No—I would characterise it as being very challenging. We could sit and discuss terminology all morning, but would that really get us very far with solving the problem? I very much doubt it. I am focused on coming up with a range of solutions that get us to a point at which people want to go into and stay in general practice here in Scotland. The issue is not easy to resolve, because it is partly about the perception of general practice, partly about how our medical schools work and, perhaps, partly about the perception in medical schools of where general practice sits with regard to other specialties. The issues are quite deep rooted and complex, and there is no solution to them. That is why in the written material that has been provided to the committee, and in my remarks to the committee this morning, a number of solutions have been touched on from recruitment at undergraduate level through to training.

However, the most important thing in all that is the vision for primary care. If we can create a vision for primary care that doctors want to be part of, many more will choose general practice, alongside other professionals who will want to work in primary care instead of other parts of the NHS. I hope that that is what we will focus on this morning.

From listening to you, I think that you are starting to think outside the box. I believe that we need more financial help for people to become doctors. Should we have incentives for people to stay in or to get into general practice? Should we have more training places? After all, something is being made of the number who are falling off. I am trying to get a constituent into a training place, but because he is a couple of points short the university is reviewing the matter. I hope that he gets the place.

As I have already said this morning, there might be an issue of—to use an old word—demarcation. If I walk into the practice with, say, a cough or a sore finger, I should just go and see a nurse, not a doctor. Is there more that we can do to reduce the amount of time that people are seeing individual doctors when they could be seeing nurses or someone else in the practice? Can we get doctors just to work with patients in a sort of health-centre setting instead of their trying to be managers, employers and so on in their own practices? Do we need to start thinking outside the box to resolve this challenge?

11:15  

Yes, we need to do that. The role of the GP is pivotal. That has been, and will continue to be, the case, but the new approach that we are taking utilises the range of skills that sit within primary care and co-ordinates it through a genuinely multidisciplinary team. I heard Alan McDevitt say at one point that 25 per cent of what GPs do could be done by someone else. That is not about providing a lesser service, but about acknowledging, for example, that pharmacists are trained to do medicines reconciliation. It is about ensuring that the patient gets the best service using the skills of the wider team, whether they are they are the skills of the physiotherapist or mental health worker. There is nothing earth shattering about that—it is a bit of a no-brainer, really. However, we need to make it happen and ensure that the contract and the model of working in primary care support that approach. That is what we aim to do.

Richard Lyle mentioned the incentives that we have put in place. The additional training places are important, but it is a challenge to fill them, as I have accepted. However, the number of applications is showing some positive signs and we are in a better place than we were last year in that regard. There is still more work to be done. It has been important to make some of those training places more attractive. We have adopted some innovative ways of doing that, with some success.

Everything that Richard Lyle mentioned is important—there is no magic bullet and we need to ensure that all those things are in place. We will not change the perception of general practice or primary care overnight; it will take time. We need to ensure that testing of new models provides evidence that will enable their roll-out. Some really interesting data are beginning to emerge from the test sites that will stand us in good stead. There is no single answer.

You may want to come back to me on this. I am sorry that I keep pressing the matter, but do your officials know how many people are refused places to train as doctors? I am particularly interested in one case, but I am sure that there are many more, and I invite anyone who is in a similar position to contact me. I want to know how many people are being refused places.

I will pick up on a couple of themes that also relate to Mr Cole-Hamilton’s question.

The context in which we are operating is that there is an international requirement for additional medical staff. The issue is not unique to the United Kingdom or Scotland; it is an issue in most of the developed world as the population ages and expectations of health increase. Therefore, our ability to recruit, train and retain our people has never been more important than it is at the moment. We also have the advantage of having in Scotland five well-regarded medical schools that attract candidates from all over the world. I think that we all want Scotland’s medical schools to be highly regarded and highly reputed. We know that they attract a high number of international students.

Because of the selection criteria, Scottish universities are able to be quite discerning. I routinely have conversations with the Scottish Board for Academic Medicine, which is the group that represents medical schools in Scotland in this context. We continue to work on the selection criteria. We get many more applications to Scottish medical schools than are offered, both from Scotland-domiciled and international students. We all accept that we want the very best of the best to be medics here—we want the people of Scotland to have the best medics they can get.

We have been working with the universities over the past couple of years to identify issues related to access. Richard Lyle is right that there are people who are not quite making it into those spaces. We have worked closely with the universities on their recruitment arrangements, but it would be inappropriate for us to determine them—candidates have to meet all the necessary academic tests. We have, however, made it clear to the universities that we want them to be in partnership with us in order to provide the NHS in Scotland with the supply of medics. We are very keen to work with them on access; the Cabinet Secretary for Health and Sport has already mentioned some of the approaches that we are taking.

There is now evidence that Scotland-domiciled students are more likely to go on to practice medicine in Scotland. Analysis from across the UK shows that students are more likely to stay to practice in the place where they went to university. It is in our interests to make sure that Scotland is as attractive as it can be. While we are doing a number of things that the cabinet secretary has outlined to try to make that attractiveness more important, we are also making sure that the attractiveness of the general practitioner role is critical.

Dr McDevitt made an important point earlier about the 25 per cent to 30 per cent of work that is being done by GPs that is not appropriate for GPs. That is wasteful and does not necessarily give the patient the best outcome, but it is also important because it makes the GP role less attractive. Richard Foggo is working—through the primary care design team, alongside Dr McDevitt, Dr Mack and various other stakeholders—to make that role so attractive that highly mobile, well-educated and well-reputed doctors stay in Scotland. We seem to be making some progress on that. Such things as the clinical fellow scheme have been very important in attracting and retaining people to stay in Scotland. If there are people who Richard Lyle believes are on the cusp and are inappropriately deselected, that is something that I would be very happy to provide further advice on.

What I will probably take away from this morning’s session is that we will not have a truly multidisciplinary approach if we do not have enough GPs in place. That is absolutely an area on which we have to focus. The Scottish Government says that there has been a 7 per cent increase in GPs but, as I mentioned earlier, in Lothian there are 39 restricted lists. I would like to understand whether the 7 per cent relates to head count or whole-time equivalents, because it does not quite add up. It seems slightly contradictory.

We heard evidence earlier about a contradiction in approach; if we truly want to shift the balance of care from the acute sector to the community, what impact are we having on health inequality? Although nobody would suggest for a moment that we do not invest in elective procedures, for example, there has been a notable increase in the number of consultants at a time when we are truly struggling to recruit enough GPs.

Is the funding matching the intent? Are the funding and the focus matching the rhetoric?

The 7 per cent relates to head count. I have said that we need more GPs. However, we also need more nurses, pharmacists and other health professionals in the multidisciplinary setting. The workforce plan that will go along with the new contract and new models for primary care is very important in that context, to make sure that we get that as accurate as we can. A lot of work is going on to make sure that, alongside the new models and the contract underpinning them, we have the investment plans and the workforce plans that will allow us to get the right number of GPs—as well as the right number of nurses, physios and other health professionals—to populate the new models and make the multidisciplinary model work effectively.

We have committed to providing primary care with an increasing share of funding. That will be subject to our meeting the needs of the new model of primary care. We are in the process of negotiating the new contract. Part of the outcome of those negotiations will be the provision of an important funding element to underpin the new model that will be delivered. All those things are hugely important.

You mentioned the need to tackle health inequalities. I have said on a number of occasions, and I repeat, that the way in which we fund practices through the Scottish allocation formula needs to better reflect the health inequalities dimension of practices’ populations. We have gone some way down that road with the formula and the funding of the deep-end practices, but I strongly believe that health inequalities need to be better reflected in the funding. That is one element of the series of negotiations that we are having on the new contract. It would be inappropriate for me to go into too much detail on that, because those discussions are on-going. All that I would say is that the process is going well, and there is a huge amount of common ground and agreement.

We also need to look at how we better link the primary care workforce with other elements of support that people who live in communities of deprivation require. In the recent debate, the point was made that we need to look at income maximisation, employability and all the issues surrounding individuals and families that impact on their health. Through a new model of primary care, we can link more effectively into the world of integration, welfare and benefits support and employability advice. There are some good examples of that. For example, the Wester Hailes healthy living centre, which is funded through the 2C mechanism, provides a one-door approach to all those services. Even under the existing contract, there have been mechanisms that have led to such innovative projects, but there is scope to do more of that and to ensure that, when someone comes through the door—regardless of their needs—they can be met by a wider team of people who can start to have an impact on the health inequalities that their family and their community face.

Thank you for coming to give evidence, and for your letter of 22 September.

There is obviously a difference between primary care funding in general and funding for general practice. Does the Government have any plans to increase the share of NHS expenditure that general practice receives?

We want to increase the share of spend on general practice and primary care within the wider health budget. We have made a commitment to increase the share of spend on that over the course of the parliamentary session, but we cannot look at the funding of general practice in isolation from the funding of the wider primary care team.

If we accept—as everyone around the table seems to have done—that multidisciplinary working is the answer when it comes to how we should deliver primary care services in the future, we must invest in the wider primary care team but, within that, we will need more GPs. As I have said, we are clear about that in the programme for government. Therefore, we will need to increase the number of GPs and to spend more on ensuring that we have a greater number of GPs.

11:30  

However, it would be a mistake to do that in isolation from the primary care team because, if we did that, we would not get primary care into a sustainable position or tackle the fact that 25 per cent of a GP’s workload could be effectively done by someone else. If we were not to invest in that wider primary care team, we would not maximise the efficiency of our primary care model and service.

Yes, we will need more GPs and, as a result, we will need to fund that additional workforce. However, that has to sit within a context of an increasing share of funding for primary care more generally; otherwise we will not get the sustainable model that we need.

I want to touch on two areas. First, on preventive spending, I want to ask you the same question that I asked the witnesses in the previous evidence session. Do you have any analysis or data on how much spending on GPs or wider primary care saves through reduced admissions to A and E and the acute sector?

Secondly, I have looked at the great big list of pilots. That is great, as it means that you are trying a lot of different stuff to—I assume—see what works. Can you elaborate on how you will evaluate the success of those pilots? What are you looking for in what you are measuring? We have previously heard that, for a lot of the pilots, the funding is for only a limited period. How will all that be rolled out? I assume that what you will do is figure out which ones work and then have a mechanism for rolling them out across the country.

I will bring Richard Foggo in in a minute to give you some more detail, but I should point out that we did not magic up these test sites; the work was done in partnership with localities and with local boards and partners. They have essentially taken the direction of travel in which we are all heading and have localised that into a model that they want to test out and which meets their local needs. There is nothing wrong with that; after all, areas are different. There is rurality; there is deprivation, and although the multidisciplinary model is the common thread, its specific application will differ slightly from area to area. As I have said, there is nothing wrong with that.

The evaluation of the models will be an on-going process—we are not going to wait until five years down the line and say, “Well, we think that worked”—and many of those test sites will then be embedded as the way in which primary care will be delivered in that locality. I believe—Richard Foggo will say more about this—that we will be getting significant change and visibility of change by as early as next year and, as part of a two to three-year process, we will embed those new models and roll out the practice and learning from that elsewhere alongside our funding, investment and workforce plans. That will allow us to scale up the change and ensure that what we see in primary care over the next few years is dramatically transformed from where we are at the moment.

Do you want to say a little bit more about the test sites, Richard?

I would just emphasise the cabinet secretary’s comments by making it clear that at the heart of this is a deeply collaborative model, the wisdom for which does not lie in St Andrew’s house. The first thing to say, therefore, is that we are working with every health board area and integration joint board to determine and support the work that they want to do to deliver those outcomes. In a sense, our evaluation supports their own evaluation of their local practice.

We are working through the Scottish school of primary care to put on top of all that a national evaluation that will allow us to identify some key themes and then to determine what is appropriate locally, regionally and nationally. Again, I do not think that we are talking about a classic top-down roll-out of one solution. Having considered the evidence that has been given today and which was given last week, I think that it is clear that there is a multiplicity of models out there to suit rural and urban environments and different demographics.

Our job is, I think, to determine the national components of that support, which in particular might include workforce and infrastructure supply. Some of the IT, digital and data issues on which I know you have taken evidence lend themselves to a once-for-Scotland approach, not to being done 14 or 30 times. Again, though, this is determined by local change. That means that our piloting work is determined by what is already happening locally, and we look to support and get behind that. That gives a sense of ownership and direction rather than a sense of St Andrew’s house setting down a strategy that people have to comply with.

There is a risk there. There are many tests—more than 80 and possibly up to 100—but that is a distinct advantage. There is a key underlying theme, which is multidisciplinary working in the context of integration. We will begin to form themes, to gather the knowledge and to determine what we can do nationally to support the local efforts, but the local efforts drive the change.

What about the preventive spend?

As some of the information that I gave Alison Johnstone indicated, the new model of multidisciplinary working is about ensuring that we provide a joined-up approach through primary care that links with other parts of the public sector, whether that is welfare advice, debt counselling, employability advice or educational opportunities. That is important in what we collectively call preventive spend. It tries to ensure that we use our primary care infrastructure and workforce to prevent ill health and intervene early.

We have not been as effective at doing that as we could. The new model can help us to do that because, by its nature, it opens up the opportunity for multidisciplinary working, such as the Wester Hailes healthy living centre. I encourage you to go along to that centre and have a look at it if you have not had the opportunity. It has preventive work at its core. It is about intervening early and enhancing life chances. Everybody from the GP through the welfare rights worker to the voluntary group has a focus on trying to build resilience in individuals, families and communities as well as providing a health service.

There is a lot that we can take from that service. It will not necessarily provide the model for every community, because some will be more sparsely populated than Wester Hailes is, but the concept of multidisciplinary working is the same. It is about joining the dots, bringing in all the skills and expertise and involving the voluntary sector more effectively to provide support to individuals, families and communities that could be better provided.

I am looking for data. If you spend £1 upstream, how much do you save downstream?

That data is available. We can provide it to you.

I would be happy to write to you with the data, Mr McKee.

Thank you very much.

I am mindful of the time, so I ask everybody to keep questions and answers brief and to the point, if possible.

All the evidence that we are getting from GPs on GP hubs points to a unanimous view that the multidisciplinary team approach is the way forward. However, last week, the convener commented that we have more pilots than there are at Heathrow. Audit Scotland has indicated that the shift to the new model of care is not happening quickly enough. It says:

“The Scottish Government needs to provide strong leadership by providing a clear framework to guide local development and consolidating evidence of what works.”

Are there any plans to provide that framework to help local development? If so, when will it be provided and when will we move from all the pilots to agreement that the new approach is the way forward and to a sustainable model with sustainable funding?

It is not a case of having pilots, getting round to evaluating them and perhaps carrying on with some. A test site is different. It is about changing the way things work and, if that is successful—which we believe that it will be because it is based on evidence—ensuring that the change happens throughout the area. We have given some flexibility, although the commonality of all the test sites is multidisciplinary working. There is none that sits outside the thrust of the way in which we have agreed that primary care should be provided in the future.

The basis of the bids was a set of criteria that was common to all. The application of the criteria took into account rurality, deprivation, the assets of the locality and what those in the locality believed would be the most effective application of the model. The national evaluation and the on-going support are there—Richard Foggo mentioned that earlier and I am sure that he can provide more detail. We envisage rolling out the practice with some changes, as there will inevitably be some changes in the light of the experience of the test sites. Nationally, we will underpin the new model with infrastructure, investment and workforce plans to ensure that we have the people to populate it on a scaled-up basis. That work is on-going while we build those supporting plans at the test sites.

To get the balance right, I would just add that, where leadership has been needed, it has been provided. The removal of the QOF and the introduction of GP clusters was done based on evidence but not based on tests or pilots, and we are watching that develop. Where there are opportunities and where there is collaboration and consensus on steps that we might take, those steps have been taken.

The introduction of GP clusters is an enormously significant move towards a multidisciplinary future. They are at a very early stage, but that was a significant step. There is a balance between local leadership and determining what is suitable for local purposes and, where necessary, taking national steps to address immediate concerns through negotiation and broader collaboration. In that context, the removal of the QOF and the introduction of GP clusters is a very significant sign of leadership.

Would you add a little bit about evaluation and roll-out?

To build on the previous point, we are working with the Scottish school of primary care to provide national support, but each project that we work with has its own evaluation. Having visited a number of those sites, we noted that local areas see evaluation as part of their own development plan—they do not do it because they are contracted by us; they are developing it for local purposes.

The changes are not waiting for national approval. Many of the test sites on the list are happening and we are supporting them, but they would be happening anyway. Those changes are being made in order to meet the changing demand of the changing local demographics. We will capture the key national themes and we will provide the national leadership that is required on workforce, infrastructure and funding, but the changes that are needed in Shetland, Stranraer, Dumbarton and Dunbar will be quite different. Those configurations will be for local partners to determine.

When we had an evidence session on GP hubs a few weeks ago, those on the panel who were involved in establishing them in Scotland could not give us a definition of what a GP hub should be or tell us which allied health professionals should be associated with them. What definition would the cabinet secretary give for a hub?

My second question is about link workers. What training and what qualifications will a link worker have and what role do you envisage them having in a hub setting?

The hub is about multidisciplinary working and the application of the hub is different in different localities. Due to the geography of a rural or very remote area, the members of a multidisciplinary team do not all necessarily work out of the same premises, although they can nonetheless work as a team. It looks and feels a bit different but the outcome should be the same. All those dots are joined up and the team works as one, hopefully bringing in wider skills such as welfare rights, debt counselling or any of the skills of social care staff—all the things that we have talked about. The hub and the multidisciplinary team model applies out of hours, and it will apply for urgent care hubs and community health hubs, which you have heard a lot about. The common theme is multidisciplinary working.

Which health professional should definitely be attached to a hub. For example, should each hub have a physiotherapist?

11:45  

There will be a core of healthcare professionals. The skills that are available in the healthcare team in a remote community will be slightly different from those that are available in the healthcare team in an urban setting because of the nature of the population, which is smaller and sparser. Although the range of skills available, whether in the healthcare team or in the voluntary sector, will be slightly different, the principle is the same. Outwith that core set of healthcare professionals, there will be members of the voluntary sector and people with other skills who can be pulled in. As I have said, the situation will vary from community to community, but the core members of the multidisciplinary team will be the pharmacist, the physio, the nurse and the GP. The GP will be at the heart of the team, pulling together all that multidisciplinary working and providing the clinical leadership that will be so critical for that to work.

As far as link workers are concerned, we already have the link worker model, which is working pretty effectively. We have said that we want to increase the number of link workers—we have made a commitment to provide 250. I know that you have expressed some concern about whether they would have the necessary skills to address some of our mental health issues. I return to Alison Johnstone’s question about how we ensure that we tackle health inequalities. It is partly a question of ensuring that the person gets to the right part of the system and sees the right person. We need to look at how we ensure availability for signposting to mental health services, which we will do through our investment of £10 million in mental health in a primary care setting. Part of that will involve utilising more effectively existing parts of the statutory and voluntary sectors, but additional capacity will be required, too. For example, Maureen Watt is considering how we can increase the resilience of mental health services in the school environment.

The link worker’s role will be to ensure that the person gets to the right source of advice, and that will depend on what their need is. Some of that will involve very early intervention, and some of it will be more complex in nature. The link worker could be the glue in making sure that the person gets to the right place.

Hi there. I want to ask about a couple of issues. Data sharing has come up as an issue that presents challenges for the multidisciplinary team model that you have described. Will you tell us a little about some of the solutions that you propose for that?

I would also like you to address the impact that Brexit might have on our NHS workforce. I know that 5 per cent of the doctors who work in Scotland are European Union nationals and that 15 per cent of the social care workforce are EU nationals. I represent the Highlands and Islands region, and I have heard anecdotally that some of the island boards think that they have a higher proportion of EU nationals working in areas in which it is harder to recruit. That issue is causing a reasonable level of concern already. Will you comment on that?

Would it be helpful if the cabinet secretary wrote to us about the legislative changes on data protection?

I would be happy to do that. It is a big issue that we need to resolve.

Absolutely. I am just mindful of the time.

I would be happy to write with more information on the issue of data sharing.

The issue of EU nationals and Brexit is important. We want to keep people working here in Scotland, regardless of whether they are EU nationals. Brexit throws up some real challenges, but the message that I want to send out now and at every opportunity is that those people are welcome, we want them to be here working in our NHS and we want them to stay here working in our NHS. We will consider how we can help to encourage them to do so.

I thank the cabinet secretary and the rest of the panel.

I suspend the meeting to allow for a changeover of officials.

11:49 Meeting suspended.  

11:52 On resuming—