Plenary, 28 Jun 2007

Meeting date: Thursday, June 28, 2007

Official Report 682KB pdf

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Health and Well-being

The next item of business is a debate on the health and well-being of the people of Scotland.

This is the fifth and final debate on the Government's strategic objectives. We have had some constructive debates in the past few weeks, and I hope that we will continue in the same vein this morning.

The Government knows that, to the people of Scotland, good health and a first-class national health service are of the utmost importance. I am sure that all members agree with that. In today's debate, I want to set out our overall approach to health and well-being and to outline in general terms our programme for the first year. However, I make it clear that today is also about listening: I want to hear the views of other members of all parties, and I undertake to respond positively whenever possible.

As members know, the Government has five strategic objectives. I have primary responsibility for the objective of making Scotland healthier—although this morning I would settle for making myself feel healthier—and that responsibility has two key elements. First, we have a commitment to improve health and tackle inequalities and, secondly, we have a clear commitment to deliver a first-class national health service.

We all know that Scotland still faces significant challenges in health improvement. Our life expectancy is poor in comparison with other developed nations and we have an ageing population. We have seen, and continue to see, growth in long-term conditions, and we face growing health inequalities.

Some progress is being made. Deaths from heart disease have fallen by 30 per cent since 1999 and there has been a steady increase in life expectancy. However, in spite of those whole-population improvements, the health gap between the richest and poorest people in our society has widened. That is not acceptable in any country, but it is particularly unacceptable in a country as rich as Scotland.

There is no doubt that smoking and alcohol continue to be key contributory factors to poor health. That is disproportionately so in our most deprived communities, which is why we have already announced that we will legislate to raise, from October this year, the age at which tobacco can be purchased from 16 to 18. We will also publish by spring next year a far-reaching smoking prevention action plan that will build on the success of the ban on smoking in public places and continue to reduce overall levels of smoking, which is the single most damaging activity to health in Scotland.

We will honour our manifesto commitment to clamp down hard on those who sell alcohol to underage children, but we also want to encourage a much wider dialogue about Scotland's relationship with alcohol—a dialogue that extends across all age and socioeconomic groups. We will look to develop a long-term strategy to deal with alcohol misuse in Scotland by building on the political and public consensus that I believe is growing on the issue.

It stands to reason that, if we are to close the health divide, we must drive improvements further and faster in our most disadvantaged communities and we must do more than just offer equal access to health care. We must be proactive in getting health care and advice to those who need it most, so to that end I am determined to build on the anticipatory care work that was started under the previous Administration.

We also recognise that the biggest challenge of all is to break the intergenerational cycle of ill health. We must do more to prevent the same problems from occurring in future generations as have blighted past and current generations, which is why as a Government we will focus more on children's earliest years by ensuring that they get a healthy start in life and helping to prevent problems from developing later at home or in school.

Will the minister respond to the opinion that was voiced recently at a conference organised by Scotland's Commissioner for Children and Young People to the effect that the training and appointment of at least 1,000 health visitors would do more for the most disadvantaged children in our society than almost anything else the Government could do?

I agree with that sentiment. The member will recall that in our manifesto we made much of the importance of health checks in schools. We plan to pilot such checks in our most disadvantaged areas, in particular. Such action is characteristic of the approach that we will take to improving health.

Robin Harper's intervention leads on appropriately to my next point. Clearly, the environment in which people live and the prosperity that they enjoy have significant impacts on their health and well-being. That is why it is so important that responsibility for housing, regeneration and tackling poverty lie within my portfolio. The work that Stewart Maxwell is leading to tackle problems of housing supply and quality is just as important for our country's health and well-being as it is for our economy.

The Government does not presume that it has all the answers to tackling inequality—that challenge will require collaboration and willingness to learn from what works elsewhere. That is why I have asked the Minister for Public Health to convene a short-life task force to refresh our thinking on the best approaches. I intend to invite health ministers from the United Kingdom and Europe to a Scottish summit on health inequalities early in the new year, so that we can share best practice and learn from one another.

The second key component of my strategic objective is the delivery of first-class NHS health services. I acknowledge that we have inherited an NHS that is in good health and that it is, through the good work of its staff, delivering quality services. However, much remains to be done. As an ambitious Government, we want to continue to drive through improvements to deliver even better NHS services in the future. We are determined to make swift progress.

I have already announced the continuation of accident and emergency services at Ayr and Monklands hospitals; a review of free personal care, to be headed by Lord Sutherland; the abolition of hidden waiting lists by the end of this year at the latest, and earlier if possible; the opening of discussions with general practitioners about more flexible access to primary care services; implementation in full of the NHS pay award from July this year; the extension of contracts for junior doctors who have yet to secure a training post; and a commitment to shape a recruitment system for the future that better serves Scotland's interests. We have also made clear our firm intention to phase out prescription charges, starting in April next year, and to introduce the HPV vaccine against cervical cancer. Of course, we are committed to using taxpayers' money to build up the national health service, not to expand the private sector.

I share the minister's sentiments about many of the honourable things that the Government has done so far. However, will she tell me the size of the private sector in health in Scotland? How many beds and operating theatres does it have, as compared with the number of beds and operating theatres in the NHS?

The private sector is minuscule compared with the NHS, but it was the policy of the Administration of which the member was part to build capacity in the private sector so that it could compete with the NHS. This Government will not continue that policy, because we believe in investment in the national health service to meet the needs of the Scottish public.

I will not take another intervention at the moment.

I have set out that proposals for service change will in the future be subjected to robust scrutiny by an independent panel and that, when taking final decisions, I will operate a policy presumption against centralisation. All in all, that is not bad for our first six weeks in office.

Will the minister give way?

I would like to make some progress.

For the longer term, I intend to develop and to publish by the end of the year a refreshed action plan to implement the principles for health care policy and delivery that were outlined in the Kerr report; I refer to David, not Andy, Kerr. The new action plan will outline the Government's health care strategy and key actions for the next three years and will focus the NHS on key targets for 2008-09 and beyond. The plan will be developed—as I believe is right—through widespread public and clinical consultation, but I confirm today that it will include a new and ambitious target for NHS waiting times: a new whole journey waiting time target of 18 weeks from general practitioner referral to treatment. I hope that all members will agree that that will represent a step change in the reduction of waiting times and that all patients will notice the difference. It will drive the transformation of NHS services and will put NHS Scotland at the forefront of international best practice. The action plan will set out how we intend to meet the target by December 2011.

The new Government has hit the ground running with a series of initiatives. The Cabinet will maintain that momentum by continuing to meet weekly over the summer to make further progress. After the recess, the Government will publish a programme setting out our proposals, which will include legislative and non-legislative measures. In the health and well-being portfolio we plan to develop legislative proposals to support some of our key objectives.

The Commonwealth games bid has the whole-hearted support of Parliament and the nation. Legislation is necessary to support the bid—the consultation for that starts today. We will build on existing consultation to modernise Scotland's public health legislation, which dates from the 19th century and needs to be updated. Our manifesto also promised greater involvement of local people in the planning of health care, and an element of direct election to NHS boards. We will consult on the legislation that is necessary for us to meet that aim. Those and other measures will form the Government's ambitious programme for Scotland.

So far, I have concentrated on issues that are specific to my portfolio, but the Government wants to usher in a new way of working. I cannot achieve a healthier Scotland and first-class health services without working with other portfolios. That cross-portfolio work is necessary to tackle the scourge of drugs in our communities, to tackle the misuse of alcohol and to focus work on early years intervention.

In addition to working across Government portfolios, we want to build consensus in Parliament and across Scotland to deliver our key objective. I will outline briefly two specific areas in which we can reach out across the chamber and make common cause for Scotland. One challenge that we face is our ageing population, which is why the Government is committed to making services for dementia a national priority. I hope that we can count on members' support on that. Likewise, I hope that we can work together to improve the position of carers in Scotland, who play a significant and often underappreciated role in health terms. We want to make rapid, significant and sustainable improvements in support for carers, including in respite care. I hope that there will be a cross-party consensus on that.

Today I have set out a serious programme for health from an ambitious Government, and I have signalled clearly our ambition and intent. I hope that I have made it clear that we want to work with all of Scotland, in and outwith Parliament, to deliver a healthier Scotland and first-class health services.

Labour set out a clear vision for our health service in Scotland—a vision based on the work of David Kerr, the team around him, members of the public, patients and the teams of experts from the Royal College of Nursing, the British Medical Association and other bodies who participated in the Kerr review process. The process drew on evidence from Scotland and abroad, and involved public meetings up and down the country. If the minister is in search of a vision, it already exists; I recommend it to her.

Although the Kerr report said that the NHS must change—I agree with what the minister said about many of the challenges that the NHS faces in Scotland—it also said that that should happen not because there is a crisis in the service but because the health needs of our communities have changed over time. At the end of her speech, the minister reflected on some of those changes, such as the growth in the elderly population and in the number of people who are living longer with chronic long-term conditions. Other issues are the changing use of our accident and emergency services and the need to tackle health inequalities and to bring about health improvement.

The vision that David Kerr set out is supported by a consensus throughout Scotland, with the exception of the current ministerial team. A preventive, anticipatory model of care is required. We must get into the communities that are most in need of health care and face up to the challenge of the inverse care law—the fact that those who need our health service most are those who currently do not use it. The previous Labour-led Administration was doing exactly that, which is why prevention 2010 and the keep well programme existed and were working.

I listened to the minister's war on words, but I believe that the consensus on the future of our health service has been put at risk by the narrow, partisan interests of the Scottish National Party. I will develop that point, although I acknowledge what the minister said about the legacy that Labour has left. We have the shortest waiting times in the history of the NHS, but I share the minister's view that there is more work to be done. Labour has delivered the highest-ever investment in our NHS and the greatest-ever number of nurses, doctors, allied health professionals, consultants and health team staff to support them. It has delivered more hospitals and equipment; the smoking ban; the hungry for success initiative in our schools; the healthy working lives programme in our workplaces; the sexual health strategy and the investment that goes with it; and supervised toothbrushing in communities. All those initiatives are making a difference and require continuing support, as the figures for coronary heart disease, stroke and cancer that the minister highlighted make clear.

However, we still face many challenges in relation to, for example, smoking, alcohol, obesity, mental and sexual health and, of course, people's lifestyles. I am pleased that the SNP shares many of Labour's ambitions with regard to how we should tackle such issues, and I will work constructively with the cabinet secretary in that regard.

As the cabinet secretary pointed out, the real challenge is health inequality. That is why we developed the keep well programme, for example, which, through the investment of additional resources in the most challenged communities and by ensuring that the NHS went out into those communities or brought people to the service, has made a real difference. In the programme, which is based on prevention, individuals and their families are analysed and risk assessed, and intervention to resolve their problems through primary and secondary care takes place at local level. The programme has been particularly successful in Lanarkshire where, of the thousands of patients who have either been brought to or been visited by the NHS, almost half have been referred to other NHS services. I hope that the minister will allow that anticipatory and preventive model to continue to deliver in the communities that need those services most.

If, as I believe the minister indicated, the SNP shares our analysis of health inequalities, we need to target resources not only at the health services but at the wider interests in her portfolio. As a result, I was pleased to hear her comments about housing, regeneration and the links between education and other matters, which should help to solve some of those problems.

The way in which we fund our national health service is central to our ability to tackle the problems, but I am uncertain whether the cabinet secretary is willing to take the tough decisions that will be needed to move the health service's resources to the communities that are in most need. As I said, Labour set out a clear and shared vision for the NHS, which I believe has been undermined by some recent decisions. For example, the rational and evidence-led health policy has gone, to be replaced by a policy in which votes, petitions and the SNP's short-term interest might hold sway over other arguments. In fact, I fear that the cabinet secretary might well have squandered what I believe was a unique opportunity that was presented by the coalition of interests around, and passion for, David Kerr's report to develop a progressive health service for Scotland that would be led by preventive, anticipatory measures, that would tackle ill-health and that would consciously shift the balance of care from secondary care services, such as are provided in the big acute hospitals, to the primary facilities that will make a real difference in changing the people of Scotland's life opportunities, life chances and health and well-being.

I reassure Andy Kerr that I am willing to take tough decisions. However, I will not knowingly take the wrong ones. I think that he is skirting around the issue of accident and emergency services at Monklands and Ayr. I ask him to reflect on the fact that my decisions were supported not only by members of my own party but by members on his, the Tory and the Liberal benches. On that issue, Andy Kerr is in the minority, not me.

If that is the case, I am in good company, because that minority includes the area clinical forums in NHS Ayrshire and Arran and NHS Lanarkshire; the weight of evidence in the Kerr report supporting the specialisation of A and E services; and consultants such as Gavin Tait and John Browning from Lanarkshire. The cabinet secretary fails to understand that Labour members supported the move from three to two A and E units in the area and the need to specialise in accident and emergency as well as in other services in Scotland. There were differences on our benches over whether the two units should be located at Wishaw and Hairmyres or at Wishaw and Monklands, but we understood the absolute necessity to move from three to two. I do not know whether the minister has read the wealth of international evidence on the matter—I can certainly pass it on to her—but it shows that patient survival rates in relation to neuroscience, heart and other treatments improve in a specialised A and E environment.

I was not going to skitter—or whatever word the minister used—around the issue of A and E, because it lies at the heart of our belief that she is radically undermining the Kerr report and the delivering for health strategy. The fact is that on this matter the SNP has failed the test of leadership.

Let us consider the SNP's record so far. Despite all the talk about hidden waiting lists, the minister has not put forward one bit of evidence—even in her responses to recent questions in the chamber—to prove that there has been any abuse of the availability status codes system or that anything has been hidden. Moreover, despite the headline-grabbing moves on cancer, the measures simply continue the previous Executive's work. The same is true of nurses' pay.

Furthermore, let us return to the key decision to reverse earlier decisions on A and E departments. Although we have not heard much about them this morning, the minister has, in the past, mentioned independent scrutiny panels. Why does she not use one of those panels to test her arguments about A and E services in Lanarkshire and Ayrshire? She seems to be saying that they can scrutinise her instructions to the health boards on how to implement her decisions, but not the decisions themselves. She is simply abdicating her responsibility to the people of Ayrshire and Lanarkshire to be fair and transparent.

Gavin Tait has already asked whether Ms Sturgeon will take responsibility for the future crisis that will emerge in emergency care, and for the lives that will be damaged or lost—for want of the best specialist care—in a second-rate A and E department. The clinical community has put forward compelling arguments on this issue, and the evidence supports the view that was set out by David Kerr in his national framework document. Indeed, during the very process of putting together that report, patient groups also supported his view. They understand the need to specialise in A and E, because, as with other NHS services, the most important issue is the outcome for patients.

The minister's strategy is simply a repetition of initiatives that were introduced by the previous Labour Administration and it is an undermining of the Kerr report's approach to health care. We have heard nothing about, for example, the SNP's promises to restore services at St John's hospital, Stobhill hospital and Queen Margaret's hospital or what will be done about the Vale of Leven hospital. That suggests that the health strategy's focus is based on narrow party-political interest, not on the interests of patients.

I want the minister to support our national health service, because it is a precious organisation full of committed people. However, I do not believe that what has been done up to now protects it. There have been warm words and hypocrisy, but the decisions that have been made undermine the whole approach to health care that I have outlined.

Earlier this morning, the Cabinet Secretary for Finance and Sustainable Growth, John Swinney, alleged that he was pro-business, but he has said no to any private sector involvement in the NHS—which is, at the moment, minimal. The Cabinet Secretary for Health and Wellbeing might say that she listens to clinicians, but she ignores them when she makes key decisions. She has also said that she supports the Kerr report, although the indications are that she does not.

Our warning to the cabinet secretary is that she should not mess up our precious NHS in pursuit of her own narrow political interests. We will support her when she is right, and hold her to account when she is wrong.

I will raise three main issues in this wide-ranging debate. However, I want to start by commending the previous Government for reducing the number of blocked beds, which, according to figures that were released just this week, has fallen from about 3,000 to 755. We were very critical of the practice of bedblocking, so it is only right that we commend the actions that were taken to reduce it.

However, we also note that it has taken £30 million a year over three years to provide the community and care places for people who leave hospital. I ask the new Government: is that level of funding, which was highlighted in the Howat report, needed to bring down the bedblocking figures even further or does it indicate the extent of underfunding of the personal care package?

My first point is about the independent sector. In that respect, I must acknowledge Andy Kerr's very innovative initiative at Stracathro hospital. Last week, however, the Cabinet Secretary for Health and Wellbeing stated that the independent sector was in conflict and competition with the NHS and that no NHS money would be put into building it up. In response to that statement, I must highlight the work of the Scottish regional treatment centre at Stracathro, which Jackson Carlaw and I visited on Monday. In this pilot project, the private sector neither conflicts nor competes with, but co-operates with and complements, the NHS. Instead of the NHS putting money into the private sector, the sector puts money into the NHS by utilising theatre capacity after 6 pm and at weekends, when the theatres would be lying empty. The facilities are leased to Netcare, which is being stringently quality audited. In this example, patients benefit through reduced waiting times and top-quality investment is maintained within the NHS at Stracathro and Netcare's facilities. There is no building up of private sector capacity—the sector itself is simply more fully utilising existing NHS resources that, as I have made clear, would otherwise be lying unused. The fact is that the private sector is helping to build up NHS access and treatment.

As a result, I ask the cabinet secretary to ensure that ideology will not stand in the way of improving patient care, greater utilisation of NHS resources or the investment of private sector money in our NHS for the benefit of NHS patients in Scotland.

Now that I have got that off my chest, I will move on to my second topic, which is mental health. I am pleased that mental health is on the agenda of the Government and of the Health and Sport Committee. When preparing for the debate, I was shocked to read that, over the past 40 years, there has been no reduction in the number of people suffering and dying from mental illnesses such as depression and schizophrenia. That contrasts starkly with the huge reduction in the number of deaths from diseases such as stroke, heart disease and cancer over the same period, which has been achieved through prevention and treatment. Late diagnosis and late intervention are still issues.

The Scottish Conservatives are committed to the inclusion of the voluntary sector—and, when appropriate, the independent sector—in the delivery of health care. In that context, I commend the excellent work of Depression Alliance Scotland, which uses self-help groups to enable people to learn useful skills for overcoming stress and anxiety, to build confidence and, importantly, to learn new ways to tackle difficult situations. Groups also cover problem solving, relaxation and how to overcome reduced activity and to change unhelpful thinking. Given that the estimated social and economic cost to Scotland of mental health problems is £8.6 million, surely there needs to be even more focus on ensuring that there is more funding for, and greater recognition of and access to, groups such as Depression Alliance.

My third topic is alcohol. I appreciate that it is on the Government's agenda and that its importance was acknowledged by Andy Kerr. The recent figures on alcohol-related liver disease are quite shocking. A death due to alcohol takes place in Scotland every four hours and the rate of alcohol-related death in Scotland is double that of the United Kingdom as a whole. There are 100,000 children in Scotland who live with a parent who has a drinking problem—we cannot lose sight of that. Furthermore, drinking by 13-year-olds has doubled in the last decade. The cost to Scotland, from the point of view not only of health and social care, but of the economy and families, is almost immeasurable.

I look forward to an extensive debate on the issues that I have raised and many others. I appreciate that we differ from the Government on the independent sector, but I hope that the cabinet secretary will visit Stracathro and keep an open mind about what is happening there. We are supportive of measures such as early intervention and the provision of high-quality support and treatment, and we look forward to working with the Government on the alcohol strategy.

Liberal Democrats are always keen to participate in discussion and debate on health and well-being and we are particularly keen to do so in the 65th year following the publication of the excellent report by Beveridge, who was a well-known Liberal in his time.

I welcome some of the principles that the cabinet secretary set out, which I will come on to. We know what the general aim is—we simply want to improve the population's health; that is the fundamental purpose of the NHS. I hope that the best outcome for the patient will be the test that the Government will apply; that is why, like Mary Scanlon and Andy Kerr, I am disappointed by the possibility of that test being set aside in favour of a dogmatic view against private providers, even when they represent the most appropriate solution for individual citizens.

We will support measures that seek to transform our health service so that it becomes not simply a service for people who have become sick, but a service that puts increasing effort into preventing people from becoming ill in the first place. To that extent, we agree with the general principle that our policies for housing and the environment in which we live must be designed to produce better health outcomes, as must our sporting and leisure activities.

As Liberal Democrats, we share the view that a key priority is the need to reduce health inequalities. The cabinet secretary mentioned the role that tackling smoking and alcohol plays in that. We must adopt the principles of preventive and anticipatory medicine, with targeting to ensure that people in deprived areas have better opportunities to be seen and have their problems dealt with at an early stage. We must not ignore the inequalities that result from the significant difficulties that arise in the provision of health services in our remote and rural communities—we must ensure that that is part of our programme to address inequalities.

The Kerr report pointed the NHS in the direction of sustaining safe local services, but it acknowledged that we must be prepared to take bold steps and difficult decisions in redesigning services to meet local needs. It asked us to view the NHS as a service that is delivered predominantly in communities rather than in hospitals.

The cabinet secretary has made a presumption against centralisation, but I say to her directly that, contrary to popular belief, the previous Executive was also opposed to centralisation. She will understand that it is not easy to give substance to that approach. Only this week, NHS Greater Glasgow and Clyde announced that it was centralising the anaesthetic services and the unscheduled medical care and rehabilitation services that are currently provided at the Vale of Leven hospital and moving them to the Royal Alexandra hospital in Paisley. It is depressing that health boards continue to act in that way, even after the cabinet secretary issued her dictum and when previous health ministers had made it clear that that was not the direction of travel.

Even more incredible was the announcement by NHS Greater Glasgow and Clyde of its proposal to close the recently established community maternity units at Inverclyde royal hospital in Greenock and the Vale of Leven hospital and to transfer them to Paisley. The proposal, which is not supported by clinicians or by local communities, simply beggars belief. That shows how difficult it is to translate into reality the wish to deliver services locally, when the people who run our health service seem to take a contrary view.

If we are to progress the more local agenda, we must expand the capability of our community hospitals and invest more in our local health centres. We must improve the availability and speed of diagnostic services and give other health providers, such as local pharmacists, powers to prescribe and to treat patients. There is also a need to increase the capacity of dental services and our ability to attract and recruit more people. I welcome this morning's announcement on the action plan to deal with waiting lists and the adoption of a whole-life waiting time schedule, which was close to the proposal in my party's election manifesto.

You have one minute left.

I do not have time to deal with the key issues that other members addressed. It is clear that mental health must become a national clinical priority. Alcohol and drug abuse remains a serious problem in all our communities. In preventive care, children's health must be the focus. Children's obesity rates are of genuine concern to us all.

The underpinning issue is what we do about the people who work in our health service and in health care generally. I welcomed yesterday's announcement by the cabinet secretary, which sought to address the problem that some of our junior doctors face. I hope that the extension of their contracts will assist them with their specific career pattern and will mean that there will not be many drop-outs among the very able people in Scotland who wish to devote their time to helping. Nurses and allied health professionals are among those who perform that key role.

The Liberal Democrats endorse many of the general principles that the cabinet secretary set out this morning, but that should not be taken as a blank cheque. We will measure progress towards the improved outcomes. If they are achieved, we will be prepared to work with the Government on delivery, but if they are not—

You must wind up, minister.

I am grateful for that elevation at this early stage.

You still have to wind up.

Indeed, but I do so in a much better state, if I may say so.

If the improved outcomes are not achieved, we will undoubtedly hold the Government to account.

We move to open debate.

Given my rapidly expanding waistline, I might not appear to be much of a maiden, but appearances can be deceptive. I am reliably informed that, for the purposes of today's debate, I am indeed a maiden.

It is an enormous privilege and honour for me to represent Livingston, which is the constituency in which I grew up. To the best of my abilities, I will endeavour to give back in kind what I have received from the community that has shaped me.

It is highly significant for me, at political, professional and personal level, to contribute to a debate on the health and well-being of our nation. None of us will go through life untouched by the NHS. Advancements in medical science and clinicians' expertise have given me and my loved ones much to be thankful for.

I welcome the cabinet secretary's speech and her explicit remarks about her dedication to tackling health inequalities in Scotland. I was surprised that a recent Federation of Small Businesses Scotland study ranked West Lothian in a poor position relative to other areas. West Lothian is a thriving and growing community, but the study gave significant weighting to the health problems that are endemic in parts of the community that I represent.

If we are serious about tackling health inequalities, we must continue to advocate that today's NHS is for everyone, irrespective of whether a person is a smoker, an alcoholic, a drug user, a teenage mother or someone who has mental health problems and, consequently, challenging behaviour. Even offenders require treatment. I am a former mental health officer, so I am painfully aware that mental health care is the Cinderella service—I am talking about mainstream mental health services, let alone the forensic settings in which I worked. There is little focus on targets or on reducing waiting times for people who use mental health services.

If we are to address health inequalities, we must start by addressing the democratic deficit in health. For that reason, I would welcome the introduction of a local health care bill in the Parliament.

I will never talk down the NHS—as I said, I have much to be grateful for—but it has been all too easy for health boards, fuelled by the centralisation agenda and their dependency on private finance initiatives, to take action without taking adequate account of the views of the community. Such an approach has been to the detriment of St John's hospital in Livingston, which is at the heart of the community that I represent. The hospital has lost vital services, which has threatened its viability as an acute hospital.

Equity of access is at the heart of efforts to tackle health inequalities. It is not acceptable for a few managers and clinicians who have vested interests to dictate where and how the rest of us receive health services. I endorse the Government's presumption in favour of local services. The Government has drawn a line in the sand. I welcome the cabinet secretary's commitment to meeting me and local campaigners and stakeholders to discuss what we can do to secure and enhance the future of St John's hospital as an acute hospital.

The cabinet secretary is aware that I have corresponded with her on car parking charges at St John's hospital. I call for a moratorium on the proposed increases in charges at St John's, pending a full review. I am alarmed and concerned that NHS Lothian is in breach of Government guidance, given its recent admission that the proposed increases of up to 100 per cent are designed in part to offset the costs of transport, which is required only because vital services have been removed. It is ironic that there is free parking at the McArthurGlen shopping centre, council buildings and Livingston Football Club, but not at the local hospital. The car parking charges are nothing short of a tax on the sick and those who visit them or spend their lives treating them. I look forward to the cabinet secretary's response.

The health agenda was a significant policy area in the previous parliamentary sessions—and rightly so. The huge task of redesigning the health service to give patients the best specialist care when they need it, the redirection of resources to the primary care services on the front line, and the pursuit of targets on the reduction of waiting times and the incidence of heart disease and cancer, were important priorities. Tough decisions had to be made, but they were supported by the clinical community, which argued the case for those decisions, even though it had not always been on the front line with us.

Targets on waiting times are a necessary mechanism, for two reasons. Clinicians, who do not generally support targets, are driven towards treating patients sooner and are not prevented from selecting on a needs basis. Targets also empower people, who know the outer limit of the period in which they should be treated. I do not think that anyone can deny the pace that the previous Administration set.

Our policy was not to grow the private sector—I correct the cabinet secretary on that point—but to expand public sector capacity. That is why we bought the Health Care International hospital, which is now a public facility. However, the overall focus should be on patients and their health. We should use all available capacity to do the best for patients.

Significant progress has been made in the Scottish health service. The Beatson oncology centre in Glasgow, which the cabinet secretary visited recently, was once described by a consultant as a "slum", but it is now, I hope, the leading cancer centre in Europe. The new Stobhill hospital and Victoria hospital are being built as we speak, as are a new secure unit and a 21st century mental health hospital on the Gartnavel royal hospital site. Glasgow, in particular, is making steady progress in its modernisation programme.

The cabinet secretary knows that a decision was made to reduce the number of accident and emergency units in Glasgow from five to two. I and many members, including Jackie Baillie, argued that there was a clear case for a third A and E at the Western infirmary or Gartnavel. I am sure that Jackie Baillie agrees that it is not too late to consider that option, which could provide a solution, particularly for her constituents who are currently faced with having to travel south of the Clyde, but who might be able to choose to go north. I suspect that the cabinet secretary is not prepared to consider the matter, but I ask her to consider whether it is viable to have only two A and E units in Glasgow, given that three such units will remain open in Lanarkshire.

I disagreed profoundly with the recommendations by NHS Greater Glasgow and Clyde that the Queen Mother's hospital, in my constituency, be closed—as did the cabinet secretary. I welcome the new hospital that is being built in the cabinet secretary's constituency, but I seek assurances from the cabinet secretary that the Queen Mum's will remain open until a new service is available and that she will ensure that the health board provides proper antenatal facilities for mums-to-be in the west end and not at Gartnavel, as is planned. That is important, if women are to lose the unique facility that they have at the Queen Mum's. Will the cabinet secretary fight, as I have fought, to ensure that that unique child and maternity service will be replicated at the new children's hospital?

I urge the cabinet secretary to consider making children's health a national priority, not least because I have an interest in child health, as I am sure that she does, in the light of the building of the new children's hospital. The case has been made for early intervention and we need to focus on children's needs.

My colleague Paul Martin has talked many times about child dental health, and we have made significant progress through the child smile campaign. There has been a 54 per cent increase in the number of primary 1 children showing no signs of tooth decay, and 100,000 children across Scotland have taken part in the daily toothbrushing scheme. There are lessons to be learned there: although more dentists are needed, it is children's toothbrushing that seems to make the difference. I hope that the cabinet secretary will consider that point carefully.

The starting well project focuses on deprived families and the wee bit of support that they need to get through the early stages when children are born into the family. I hope that the cabinet secretary will continue to support such projects. I tend to agree with Scotland's Commissioner for Children and Young People when she says that it is worth considering what health visitors can do to help families.

I know that it is not within the cabinet secretary's brief to enact any changes on free school meals. However, if we are to improve the health of children, the threshold for eligibility should be increased now. There has been a commitment to consider the issue as part of the comprehensive spending review, but I ask the cabinet secretary to lobby her colleague, the Cabinet Secretary for Education and Lifelong Learning, to lift the threshold so that all the poorest families can benefit from free school meals.

What a fantastic opportunity the cabinet secretary and her team have. Although that is true for every department, it is truer still for health: the SNP Administration has no record to defend, no legacy and no baggage. It has an opportunity but also a testing challenge, for at the end of this session of Parliament the public will judge the Government on the results achieved and the decisions reached. The SNP members' period in charge of Scotland's NHS will then constitute a permanent record for which they will be held to account. They can bet on that.

The Government's early actions are encouraging, and we share its concern about the progressive centralisation of services that galloped ahead with rampant abandon under the previous Administration. For me, it was one of the most peculiar paradoxes in political life that a party that marched in the streets against phantom hospital closures when I was a teenager should, when it was in Government, lead the charge to downgrade so much hospital provision.

The member talks about downgrading, and he has talked about accident and emergency units, but it is interesting that he does not mention the seven community casualty units in Ayrshire and Arran and the five in Lanarkshire, which are local.

The member interrupted me when I was only about three sentences into my second paragraph, so he did not give me time to mention those things. I do not deny the Kerr report, or the investment that has been made, but accepting that key major trauma services and other services should be centralised is not the same thing as accepting the need for a headlong rush to centralise, even where Scotland's geography and an unconvinced public demand an alternative solution.

We support the Government's approach to Ayr and Monklands and we continue to support the people elsewhere who are working hard to ensure that the very real concerns for public safety in their communities are not sidelined. As regards the Victoria hospital and Stobhill hospital in Glasgow, the public remain largely unconvinced, despite all the platitudes that they have been offered. The same is true in Edinburgh as regards St John's hospital, and it is especially true as regards the Vale of Leven hospital, as Ross Finnie has said.

Time does not permit me to discuss this at length today, but although I appreciate the minister's difficulty—unpicking a strategy that she and her team did not support in the first place is a huge if not impossible task—I ask even now that she listen positively and urgently to those who argue for additional services to be provided at key locations, within the current strategy, to meet the concerns of those who believe that what is in prospect is not only foolhardy but dangerous. She will have our support if she does that.

The Labour Party members sitting opposite regularly say that they will take no lessons from the Tories, but I ask them to set aside their prejudice and take just one—and I say this particularly in response to the admittedly impassioned remarks from Andy Kerr. Parties lose elections for a reason. Although many other factors were at play, too, I have never known so many traditional Labour voters alienated by their own as I have over the issue of health and changes to the hospital network. There is an acronym in business—SARAH—which stands for shock, anger, rationalisation, acceptance and finally hope. Since May, I have watched Labour members wrestle through their shock and anger, but I see little sign yet of any true rationalisation, let alone acceptance or hope. Rather than rationalisation, I see denial. Let me spell this out for them. Are we to believe that, in four years' time, they will say to the electorate, "You know those hospital downgrades that the SNP and the Conservatives reversed? Vote for us, because we are going to implement them after all." If that is inconceivable, at some point a Labour Party health spokesman will have to stand up in the chamber and say, "We were wrong." When that admission is finally made, it will be a measure of Labour members' determination to govern again.

If NHS Lanarkshire fails to keep a full, traditional accident and emergency service at Monklands—as currently exists—will the member say that the minister's decision to reverse the cuts was a failure?

My point is that Labour members say that people did not understand and did not grasp the concept, but they did. Labour members say that people will soon be grateful for all that they had been doing, and they say that the election result was just an aberration. They say that people were not left wing enough and that it is only a matter of time before Labour gets back in. That will not happen. On this issue the Labour Party was wrong, and its members will finally have to admit that.

We will look with interest at proposals for free prescriptions and with sympathy at proposals for people who are afflicted by chronic conditions. We accept that health boards have acted in some cases with a seeming lack of regard for public opinion—with arrogance, even. We also await with interest proposals for elected health boards. There are other recent announcements that we welcome and support. Marks should be awarded for a good start.

We look forward to hearing proposals on alcohol, smoking and the general diet and fitness of the nation, and we look forward both to the updating of public health legislation and to action on dental health.

I agree with Mary Scanlon: when the Government acts in the interests of patients first, we will offer our support. However, we note with concern that the Government states its ambition for a right to a minimum waiting time while at the same time it rehearses its dogma against any greater role for the independent sector, which might help to bring about that minimum waiting time. Let us accept that between the public and the private sector another sector exists—the independent sector. The pilot at Stracathro, where an independent provider is working exclusively for the NHS and is using NHS operating facilities in the evenings and at weekends, is reducing waiting times. That is a potentially magnificent model and, in the end-of-term spirit of consensus, let me pay tribute to Andy Kerr, who backed the initiative. In a few months, we will have an even better idea of the fruits of the pilot. I urge the Administration to hold its breath before denying that a roll-out of the initiative should be part of a comprehensive solution in the fulfilment of a stringent objective to be set out in the Administration's forthcoming legislation. Why should the Government deny itself a successful working model for progress?

I congratulate the business managers on scheduling this debate on health and well-being for the morning after the Scottish Parliamentary Journalists Association dinner. It offers an opportunity for many of us to reflect—soberly—on the health risks of excessive alcohol consumption and the health benefits of a good night's sleep. I welcome this debate and I am pleased to be able to participate.

I want to use my time to reflect on an issue that is of serious concern to my constituents. The issue was touched on by Ross Finnie, and I am sure that similar concerns are shared in other particularly rural communities.

The Arbuthnott formula that is used for calculating health service funding is in need of urgent reform. The indicators that are used under the formula for calculating deprivation are flawed, with the result that places such as Orkney are at a disadvantage when it comes to trying to deliver high-quality health care. I fully accept that no formula is ever likely to be considered perfect, and that overrefining criteria can come at the cost of increased complexity and reduced transparency. However, there is a need—and there is scope—to make the formula less simplistic in a number of respects, which can serve only to better match health funding to health need.

To give an example, the employment statistics that are used in the current formula are too narrow and too crude; they take into account only the number of people unemployed and do not reflect the nature of employment. In Orkney, but also across the Highlands and Islands and in much of the south of Scotland, low wages rather than unemployment are a real problem. A formula that took account of the type and quality of employment, and not just the number employed, would more accurately reflect deprivation and need.

Similarly, the present Arbuthnott formula is too simplistic in relation to housing. The rate of home ownership in Orkney is relatively high, but so too is the proportion of people who live in substandard accommodation. Fuel poverty is also a major issue; I fully accept that that is a nationwide phenomenon, but Orkney's climate—notwithstanding changing weather patterns brought about by global warming—adds an extra dimension to the problem.

Car ownership is another measure used by Arbuthnott that paints a somewhat misleading picture. The extent of car ownership in Orkney is high, but that is a reflection less of wealth than of travel distances and the lack, more often than not, of public transport alternatives. Cars are an everyday necessity; they are a lifeline not a luxury—and, with the cost of fuel significantly higher in the islands than elsewhere in Scotland, a not inexpensive lifeline at that.

The age of the car pool in Orkney illustrates shortcomings in the current Arbuthnott indicators. Almost a third of the cars in Orkney were registered before 1995, compared with 14 per cent in Scotland as a whole. I accept that car ownership should be a measure, but the age and value of the cars should be taken into account.

Arbuthnott consistently underestimates the impact of remoteness on the cost of providing health care. The formula is based largely on calculations of distance travelled over land, and so does not account properly for the time and cost of sea travel, which can and does add significantly to the cost of delivering public services, including health care.

The cabinet secretary and others have acknowledged the additional demands of delivering health care services to an increasingly ageing population. That is felt particularly acutely in my constituency. There is a need for improved statistics that better reflect changes in the population and age structure. Current statistics do not identify changes quickly enough, are based on postcode areas that are too large to pick up significant local differences in places such as Orkney, and are not sensitive enough.

A review of the Arbuthnott formula has been taking place. Other members will doubtless have issues that they feel should be better reflected in any revised formula. However, I hope that the cabinet secretary will accept the compelling case for adjusting the current formula better to meet the needs of those who live in rural and particularly island areas.

I begin in a different vein from other members by congratulating the people of Scotland on electing an SNP Government. I also want to thank the Parliament—this new, SNP Parliament—for raising the game, not just for the Parliament, but for the hopes and aspirations of the Scottish people. A healthy mind needs a healthy body, and people are enthused by the actions of the SNP Government, which will go a long way towards promoting health and well-being. I am sure that other members speak to people in pubs, clubs and restaurants. The people I speak to are full of new hope, ambition and confidence in the future. [Interruption.] Opposition members may shout, but if they spoke to people in the street, they would know that confidence—not just in the people, but in Scotland—is booming.

The previous Administration never gave the Scottish people that confidence. For too many years, the Scottish people were told that they were not good enough; that they had to limit their hopes and ambitions. The SNP Government has raised the bar, not just in Scotland, but throughout the world. It is seen as a world leader for its commitment to and aspirations for the Scottish people. With that new-found belief come responsibilities. I know that the Government realises that, and I welcome the commitment to ensure that the national health service is run for the people and not for profit. The public desperately want that and that is why Labour paid the price.

I hear what the member says about a public service. Will she comment on the cabinet secretary's views on how we fund housing, which is increasingly by using private capital? Does she welcome that, since health funding seems to exclude that approach?

We need take no lessons from Johann Lamont after the fiasco of Glasgow Housing Association. She was told in 2004 that there was not enough money for second-stage transfer, but led the people in Glasgow astray until December last year by saying that second-stage transfer would go ahead.

The NHS pay award was mentioned. The Health Board Elections (Scotland) Bill was proposed by a Labour member. Such elections would go a long way towards fulfilling the commitment to transparency and honesty. As a Glasgow member, I welcome the proposal for a Commonwealth games bill—that will improve the confidence of the people of Glasgow. I echo Pauline McNeill's comments. I have met and written to the cabinet secretary about the fact that there are only two accident and emergency departments in Glasgow. I urge the cabinet secretary to consider that and perhaps to meet interested and concerned people from across the parties.

The FSB report to which Angela Constance referred paints a worrying picture of Glasgow, showing that it has the poorest ratings of all local authorities for education, health, employment and inequality. That is after 10 years of Labour rule at Westminster and eight years of Labour and Liberal here at Holyrood. Glasgow has been portrayed as the sick man of Europe—a sorry portrayal that it is time to rectify. I welcome the announcement of a task force and a summit, and I hope that Glasgow will be looked at in particular. It is imperative that we close the gap between the rich and the poor, and I urge all Glasgow members to sign my motion on an action plan to consider why, despite the money that has been spent over the years on various issues in Glasgow, the health and well-being of the people has not improved. Many initiatives have been promoted—throughout Scotland—but the gap between the rich and the poor is getting bigger. In some areas, initiatives are not working, and we need to find out why. That is why I am taking on board the need for an action plan. I do not want any extra money from the Cabinet or elsewhere; I just want all-party support to consider exactly what is happening in Glasgow.

In the short time in which the SNP has been in Government, we have gone a long way towards improving the health and well-being of the country, with free school meals for children in deprived areas, the extension of free nursery care, the abolition of the graduate endowment fee and other positive measures that have been mentioned. The SNP Government has given the Scottish people renewed hope and confidence. That will go a long way towards improving their health and well-being.

If Duncan McNeil sticks to time, I will be able to give Jackie Baillie two or three minutes.

I will try to stick to time. This morning's debate reflects how difficult it is to focus on the issues faced by the health service and on the health of the people of Scotland. The debate—and the election—has been dominated by public-private finance versus trusts; local access; A and E; and so on. This week's news on the closure of midwife-led maternity units in Inverclyde and the Vale of Leven tempted me to go into that issue this morning.

Will the member give way?

I am sorry, but my time is limited.

Suffice to say, the Inverclyde community and I will hold the cabinet secretary to her word, and to her presumption that there will be no centralisation of services and that an appropriate weight will be given to patient and public opinion. I am sure that she and her colleagues will take into account the impact of the closure of the midwife-led unit on the maternity strategy, not just in Inverclyde but in Scotland.

However, I want to return to deprivation—and it is worth considering why it is that in communities where there is high deprivation, there is lower use of midwife-led maternity units. All the issues that I mentioned conspire against us and divert us from the focus that I believe the Parliament and the new Government should have on health inequalities. The big issue explored by Professor David Kerr was poor life expectancy and the long-standing illness that affects Scotland's most disadvantaged people. That has been described this morning as Scotland's shame. Hand wringing goes on about the reports that are regularly published, but it is difficult to act.

As the cabinet secretary and others mentioned, there have been some improvements in life expectancy—good news, we might think—but yet again those figures show that the more affluent have benefited. The gap is widening, not narrowing. I am sure that there is broad agreement on the reasons for that—members have touched on how life circumstances relate to health, unemployment, poor housing and poor education. We have also spoken about bad lifestyle choices, such as alcohol, drugs, lack of exercise and poor diet, but I will focus on access to primary health care services and the difference that such services can make. It used to be considered that health care services did not have a significant impact on people's health. With medical advances, it is recognised that access to effective health care can have a significant impact. Evidence to the Health Committee in April 2006 recognised that 30 to 50 per cent of the gap in life expectancy results from reduced access to health care. If we improve access, we can improve people's life chances.

There is a high uptake of health services by people living in deprived areas. The question, however, is whether it is high enough to meet the needs of those communities. Indeed, is the care that is being made available to them appropriate to their needs? The same number of GPs serve the poorest 20 per cent as serve the top 20 per cent. GPs in deprived areas are running to stand still. They deal with more people with more problems. As a consequence, poor people spend less time with their GP, are less likely to be referred to a consultant or to receive in-patient care, are more likely to receive emergency care, are less likely to get appropriate medicine and manage their health properly and are less likely to have their children immunised.

The question is how we respond to that challenge. Behavioural change campaigns can actually widen health inequalities, because more affluent people are more likely to take up the advice. The gap is not narrowing and the situation will get worse unless we do something about it. Improving individual circumstances and providing better education, jobs and housing can make a change, but that takes time. We must surely recognise that the quickest way to make an impact on health inequalities is to target services in the most disadvantaged areas. We should be prepared to take a radical step to enhance access to health services for the disadvantaged.

I do not think that that is an easy ask for the Parliament. Rather than forming another task force or group, I recommend the report of the Kerr sub-group on health inequalities as essential reading. The case for change is there. The case is outlined for moving resources to meet the need that is there, concentrated not just in the west of Scotland but on some streets and in some neighbourhoods in all our communities. The test for the new Cabinet Secretary for Health and Wellbeing and the new Government is whether they have the political will and the courage to do that. Indeed, the Parliament, not just the cabinet secretary, needs to meet that test.

I am truly grateful for being given time to speak in the debate. It will not surprise the Cabinet Secretary for Health and Wellbeing or other members to hear that I will talk about the Vale of Leven hospital. I make no apology for reiterating my concerns and those of my community. I will continue to do so until such time as the future of the hospital is secure.

I will start with the actions of NHS Greater Glasgow and Clyde. Frankly, its arrogance has been breathtaking. It announced its plans—and they include the wholesale transfer of services away from the Vale of Leven hospital—a mere two days after the appointment of the Cabinet Secretary for Health and Wellbeing and on the very day that the First Minister announced his intention to keep health services local.

To add insult to injury, despite clear public opinion telling the health board that it had got things wrong and despite the proposals from the Cabinet Secretary for Health and Wellbeing for independent scrutiny, NHS Greater Glasgow and Clyde confirmed just yesterday its decision to withdraw a range of services from the Vale. Anyone with any sense would have taken their time to reflect on the matter, to look again at the proposals for the Vale of Leven hospital and to consider all possible options. But no, NHS Greater Glasgow and Clyde ploughs on regardless.

Not only are we to witness the wholesale removal of services, of the medical assessment unit, of integrated care—meaning no emergency care at the hospital, day or night—of coronary care and of the community midwife delivery unit, but to add insult to injury the health board wants us to travel to the Royal Alexandra hospital in Paisley. I do not intend to give members a geography lesson about the River Clyde, but I suggest that they refer to a map. It is extraordinarily difficult to get to the RAH in Paisley from my constituency. There is little direct public transport there. People need to travel for two and a half hours, by a combination of train and bus into Glasgow, bypassing five other hospitals en route.

I remind members of the words of the Cabinet Secretary for Health and Wellbeing, when she spoke about A and E at Monklands and Ayr hospitals:

"It is my view and the Government's view that, given the circumstances that are involved in these cases—the geography and demographics, the high levels of deprivation and ill health, and the concerns about access and public transport—A and E services at Ayr and Monklands should be maintained."—[Official Report, 6 June 2007; c 391.]

It will come as no surprise to the cabinet secretary to hear that all that applies to the Vale of Leven hospital. NHS Greater Glasgow and Clyde ignores the cabinet secretary's approach, however.

Time is short, so I will quickly raise three specific issues. The first is anaesthetics, which is key to sustaining services at the Vale of Leven hospital. Just what models did the health board consider in that regard? There is little evidence to suggest that it examined closely the integrated care model that was operating at the Vale of Leven. I know for a fact that the board did not analyse the statistics for the 7,000-odd patients who have used the medical assessment unit. I am told that there is one episode a week that requires the intervention of an anaesthetist. Potentially, that means 52 visits in 365 days. One wonders if there is perhaps a shortage of anaesthetists. There are no such things as vacancies. There are 169 anaesthetists, according to NHS Greater Glasgow and Clyde itself.

Secondly, I will mention risk. We are told that clinical safety is paramount, and I do not disagree with that. What about the risks for somebody who has to spend more than an hour in the back of an ambulance to reach hospital?

Thirdly, and simply, we do not want to have to go to Paisley. Instead, we want a north-of-the-river solution. I associate myself with the comments that Pauline McNeill made about A and E services in north-west Glasgow.

I close by saying to Jackson Carlaw that the history of the Vale of Leven hospital is very different. Decisions to remove services were made in the past by clinicians, not ministers. The decision on the Vale of Leven hospital will, in my view, be the first real test of SNP health policy. I welcome Nicola Sturgeon's presumption against centralisation. She knows that I will do all that I can to help. For people in my community, however, she must pass that test.

This has been an interesting debate. Inevitably, at this stage, it has covered general principles and has been a take-note debate. It is difficult to find enough time to cover the wide canvas that is embraced by any health and well-being agenda.

I will pick up some of the interesting points that members have made, starting with one that has just been referred to by Jackie Baillie, although it was first made by Pauline McNeill. It is about what is treated by NHS Greater Glasgow and Clyde not as the settled will of the people of greater Glasgow, but as the settled will of NHS Greater Glasgow and Clyde.

One of the great disappointments that the Cabinet Secretary for Health and Wellbeing will have to address stems from the fact that many of us supported the decision of the then Minister for Health and Community Care to abolish NHS Argyll and Clyde, not just because it had incompetently run up an enormous deficit, but because it had shown itself to be both unwilling and unable to address the problems of delivering care locally in its area. It was a huge disappointment to many of us that NHS Greater Glasgow and Clyde started with the presumption that the former Argyll and Clyde bit could just be tacked on, leaving any existing health delivery programme for that area completely unaltered. Pauline McNeill covered that point well.

We will not get health care delivered locally and we will not be able to address problems in the west of Scotland north and south of the River Clyde unless greater flexibility is shown by the people who now run NHS Greater Glasgow and Clyde. I hope that the Cabinet Secretary for Health and Wellbeing will be able to take up some of the suggestions that have been made in that respect.

I welcome Liam McArthur's contribution to the debate. He filled in some of the detail of what will be required if we are to treat health inequalities, particularly in remote and rural communities. The previous Administration did much work on the Carstairs index, which is a curious index of deprivation. It almost suggests that, if people have ownership of or any access to a car, they cannot be deprived in a rural or remote area. That is a perverse way to compile statistics, and it militates against serious attempts to address problems in such areas. We have addressed the use of the Carstairs index in some areas, but clearly not in the formula that is used for health care. I hope that the cabinet secretary will take on board the comments that my colleague Liam McArthur made in that regard.

In these early days, we are happy to support wider and broader delivery of local health care, greater attention to preventive care and a general addressing of waiting times. However, a debate such as this allows the Executive and the Opposition to articulate only general principles about where we want to be and, although we are prepared to give general support to much of what the Executive has talked about, we need to see the detail that will support the proposals. As the cabinet secretary indicated in the Health and Sport Committee the other day, she is prepared to give priority to a range of services and issues. We look forward to hearing more about how those aspects will be delivered.

We accept the broad thrust of the idea that, if our health and well-being is to improve, and we are to build on what was achieved by the previous Administration, a more holistic approach will be needed. As I said, adding to the health portfolio issues that seek better outcomes from the environment agenda, the housing agenda and exercise, sport and leisure activities, must be specified in terms of delivery. The Liberal Democrats view the addition of those elements as enhancing a health service that, as the cabinet secretary has acknowledged, is in reasonably good health.

Our health service is demand led. It constantly has to meet the increased expectations of our citizens and incorporate improved technology that allows us to deliver better outcomes for our citizens. We have to make that step change.

We are happy to accept the good will that the cabinet secretary has set out in the general principles of this debate. However, I repeat that it will be necessary for us to have more focused debates on aspects of care delivery. We will be interested to hear in greater detail what is required to improve the health and well-being of the citizens of Scotland.

We particularly welcome the strategy on waiting times that was announced by the Cabinet Secretary for Health and Wellbeing this morning. That is in accord with what the Liberal Democrats were saying during the election campaign.

We welcome much of what the cabinet secretary has said and hope that those principles can be transformed into an agenda that we can scrutinise in the chamber and in the Health and Sport Committee. We look forward to working with the Cabinet Secretary for Health and Wellbeing and her team to try to deliver for the people of Scotland.

I want to touch on a number of subjects and I hope that the minister will listen as I do so.

The British Lung Foundation, the British Lung Foundation Scotland and a number of constituents have raised with me issues relating to chronic obstructive pulmonary disease, which encompasses chronic bronchitis and emphysema. The minister will be aware that COPD is estimated to affect 18 per cent of males and 14 per cent of females aged between 40 and 68. Nearly 130,000 people in Scotland live with COPD, but three quarters of them remain undiagnosed. COPD is particularly prevalent in the more deprived neighbourhoods of Scotland and it is more prevalent in Scotland than it is elsewhere in the United Kingdom.

COPD costs the national health service £138 million a year and the cost of working days lost as a consequence of COPD is estimated to be between £300 million and over £400 million. Scotland is the only country in the UK that has not developed specific policies to improve care for patients with respiratory disease. Northern Ireland has a 10-year plan, Wales has something similar and the Government announced in June 2006 that a new national service framework specifically for COPD would be developed in England—and work on it has already started. Why does Scotland not have a specific plan to improve care for people with COPD? Four health board areas have managed clinical networks that approach the problem. Perhaps the best solution would be to extend those to all health boards in Scotland.

The British Lung Foundation Scotland is calling for NHS Quality Improvement Scotland to develop new standards and services for COPD sufferers. It does not want the Scottish Executive to wait until publication of the report on the national service framework in England because that will not occur until 2008, which might mean another 10,000 people in Scotland die as a result of COPD before anything is done. The British Lung Foundation Scotland is calling on the Executive to take action to help people with COPD as soon as possible.

I would like to use this opportunity to talk about an extremely important situation in my region. Nicola Sturgeon will be aware that I recently copied to her a letter about dental provision in Oban that I sent to the chairman of the Argyll and Bute community health partnership. Since then, things have got worse. At the end of last week, 2,000 people in the Oban area lost NHS dental service provision when that service ceased to be provided by the Argyll Square practice.

The state of affairs is hugely serious. Although emergency NHS dental services will be provided by two dentists in Lorne and the Isles hospital, I share the strong desire of the local CHP to see new NHS dental provision established for the community as soon as possible. The hospital is keen to expand services such as endoscopy and colon-cancer screening, and all the spare space in the hospital will be needed for that expansion, so it is vital that the new location for dentistry is outside the hospital. That new location must be immediately identified in the interests of the people of Oban. I am sure that the minister agrees that access to dentistry is a basic entitlement.

As other members have said—and as the media have often reported—the previous Lib-Lab Administration's record on dentistry was on the poor side of appalling. We look to the new Administration to help communities, such as Oban, that need dental treatment. I would be grateful if the minister could set out today what the Executive can do to help my constituents who have been left without an NHS dentist.

Will the member give way?

I am sorry, I need to press on.

Since becoming my party's sports spokesman, I have had the pleasure of meeting a number of sporting organisations and I look forward to meeting many more over the next few months. I am pleased that Stewart Maxwell recently told me, in a written parliamentary answer, that the new Executive is committed to fully implementing "Reaching Higher". Can Mr Maxwell give me further details today about when he will set out concrete proposals for implementing those plans? The Scottish Conservatives will support positive proposals to increase the amount of sport of all types, as we recognise that that is crucial to our attempts to tackle rising obesity rates and to ensure that our children develop skills that will ensure they have better health.

I would like to associate myself with the remarks that Jackie Baillie made about the Vale of Leven hospital. I know how important that facility is to people in Helensburgh and Lomond. The RAH in Paisley is no substitute, and the north-of-the-river option has to be seriously considered should the worst happen and the Vale of Leven be closed.

The Scottish Conservatives will work with the new Executive to improve the health and well-being of the people of Scotland. We will support it when we think that it is doing the right thing. However, as Mary Scanlon said, we believe that political dogma has no place in planning health services in Scotland. We were disappointed with the cabinet secretary's outdated attack last week on the independent sector. What matters should be what works. If, as in the case of Stracathro hospital, the independent sector can complement the NHS, we should welcome that and seek to expand complementary working relationships elsewhere.

We have had another interesting and constructive debate about the challenging issues that we face in relation to health. I repeat my willingness to work with the Executive on public health, health improvement and heath inequalities. I support the shared ambitions that were set out prior to the election—on, for example, GP treatment within 18 weeks.

I commend to the cabinet secretary the commitment Labour made to set a target waiting time for those who need to see allied health professionals. The opportunity that we have to improve health and well-being by using the primary care sector is the key to unlocking the health potential of Scotland. Labour set that target to ensure that we would deliver on our commitment in a new Government. The cabinet secretary now has the opportunity to do so.

I share Mary Scanlon's concern about the new SNP Government's position on the private sector. Neither I nor any minister in the previous Executive sought to increase the private sector's role or build a marketplace for it. If the Executive has any evidence to the contrary, they should bring it to the Parliament. We sought to act when the NHS needed additional capacity in the short term or when it suited communities in the north-east. If we had not acted, people would not be able to go to the Golden Jubilee national hospital, which we brought back into public ownership from the Arab bankers who owned it previously. In doing so, we created a centre of excellence in treatment that puts patients at its heart.

Labour increased annual health spending per head from £900 in 1997 to the present level of more than £2,200. Of that, 92p is spent on Stracathro hospital. Ministers say that the private sector is rampaging through the health service, but in fact the health service uses the private sector as and when it needs to, not to build a marketplace or capacity for the private sector but in the interests of patients. Ministers should spend some time speaking to patients who have benefited from those services.

Some £15 million was allocated to Stracathro. Would the member have approved an NHS bid to deliver the same facility under the NHS if one had been put to him?

That could not be done within the structure of the NHS in Scotland. Why would we create in the public health service a new service, which would be there for ever, to deal with a short-term problem in relation to waiting? Our approach allows additional capacity at the time of need and in the interests of patients. When the Minister for Public Health responds to the debate, will she tell me, without breaching commercial confidentiality, whether the cost of a procedure is the same as, less than or more than the NHS charges?

I commend to the member the speech that I made last week. If he reads it, he will see that I did not rule out the NHS using existing capacity if there is a short-term need. What I ruled out was the investment of taxpayers' money in building up private sector capacity to compete with the health service. If the member is now saying that he agrees with that, can we proceed with some consensus on the future of the public national health service?

That is exactly the policy that the previous Executive adopted. The spinners in the cabinet secretary's party should take heed. I read her press release on the Executive's website and I know what she was trying to say, but I also know what her spinners said about ending use of the private sector in our NHS. I will give her the press cuttings if she wants to see them.

I share Mary Scanlon's concern about mental health. Other members mentioned that, too, and I congratulate Angela Constance on her maiden speech. There are mental health targets in Scotland on, for example, the use of antidepressants and re-referrals to secondary care mental health services. We set those targets. I argue that Scotland's mental health strategy is admired throughout the United Kingdom and indeed the world.

Ross Finnie set out some of the other challenges that we face. I commend to the chamber the cabinet secretary's recent comments on independent scrutiny panels. When will we find out about those? How will they be set up? Will the Nolan principles apply? Will the Office of the Commissioner for Public Appointments in Scotland be involved in the process? How will the panels affect the role of the Scottish health council? Why will the cabinet secretary not allow them to look at her decisions on accident and emergency departments, such as the ones that she made recently?

Will the member take an intervention?

No. I have taken a few interventions and I want to make progress.

Will independent scrutiny panels be accountable to the Parliament and its committees? We need to address the many questions about the panels and I would be interested to hear more information about them.

Pauline McNeill mentioned the opportunities and chances that we took on, for example, oral health. There have been radical reforms and improvements in oral health, particularly in the Glasgow area. Pauline McNeill also sought assurances on the Queen Mum's hospital. I will be interested to hear the minister's response.

Jackson Carlaw made a point about denial. I am not in denial about the points that I was trying to make to communities throughout Scotland about the evidence that I had on their health, the health of their relatives and friends, and the improvements that we could make to their services. I did not convince them of the need for change. I am not kidding anyone on that, but I will happily spend some time with the cabinet secretary at her leisure and go through the international evidence, the UK evidence and the Scottish evidence, including the evidence that was given to Professor David Kerr. The evidence tells us clearly that, when we bring A and E trauma services together and allow clinicians to have subspecialty skills and training, that improves the outcome for patients and fewer people die.

The cabinet secretary will often be faced with evidence that an action will save patients' lives and improve outcomes in relation to heart conditions, trauma or specialist injuries. When that happens, one has to decide whether to put patients' interests, or political interests, first. I think that she has failed that test. I am happy to spend some time with her and the Minister for Public Health and go through the evidence that was available to me. I am not in denial about the concept: what I am in denial about is the fact that we are not listening to internationally peer-reviewed evidence from clinicians that tells us the right way forward for our health service. People accept such evidence in other specialties in the health service, but for some reason not in A and E.

Sandra White talked about the confidence of the nation. I spent the past eight years listening to the SNP talking down Scotland on every occasion, including First Minister's question time and every other set of questions in the Parliament. Today, thankfully, the cabinet secretary mentioned some of the good things that have occurred in our national health service and acknowledged some of the good work that we have done. I hope that that will allow us to continue to work constructively on oral health, smoking cessation and prescribing statins—things that have made a remarkable difference to the health and well-being of the people of Glasgow.

Those with the most challenged health profiles, who most need the health service, die in the shadow of our general hospitals. It is not general hospitals that make a difference for them but the community nurses and preventive work in schools, pubs, clubs, communities and libraries. That is why I am so concerned about the destabilisation of the findings of the Kerr review, which proposed shifting the balance of care from the big hospital environment to the community, because that is where we will make a real difference to the nation's health and well-being. The cabinet secretary simply does not understand that argument.

I genuinely want to work with the Executive. We have a shared interest in the precious thing that we call our national health service. However, decisions must be based on evidence, on need, and on the future health and well-being of our nation. If the cabinet secretary promotes that idea and works on that basis, we on the Labour benches will support her in that.

It is a privilege to close this debate on the health and well-being of the people of Scotland as Scotland's first Minister for Public Health. I apologise for my voice: I have the same bug as the Cabinet Secretary for Health and Wellbeing. I was generous enough to give it to her. I hope that members will bear with me.

I welcome the widespread recognition throughout the chamber of the importance of improving health and well-being. There has been a lot of consensus this morning. We have already proved that we can work together to put in place enlightened, world-leading legislation on smoking and mental health. I am greatly encouraged by those successes as well as by the support for further action that has been given today, because achieving our goals requires a long-term programme of sustained action, not quick fixes. Most important, we must join forces with the people and communities of Scotland in sustaining and improving health. The Government is determined to provide the leadership that is required and has structured government to facilitate that, but improving the health and well-being of the people of Scotland is everyone's business.

For our part, ministers are committed to working together across portfolios to tackle the most important issues. We will work together to support families during children's early years of life. Pauline McNeill made an important point about that. It is with the next generation of Scots that the benefits of early intervention will generate the biggest payback. We will tackle problems such as the rising levels of childhood obesity. Children need a healthy environment that encourages them to be active and eat well. That is why we are investing £5 million in piloting free nutritious school meals for pupils in primary 1 to 3, focusing on some of Scotland's most deprived areas.

I welcome that measure, but does the minister support extending provision to cover all children? Will she do that immediately after the comprehensive spending review?

We are actively considering that as part of the comprehensive spending review. We want to build on the success of the hungry for success school meals programme, which we pay credit to the previous Administration for introducing. The overwhelming evidence is that healthy children become healthy adults and are therefore more likely to avoid diabetes and other risks to their well-being.

Improving Scotland's dental health, to which several members referred, is also a priority. We need to ensure that children receive early preventive advice and treatment, particularly in areas where children are less likely to attend for regular dental treatment. We will introduce a school-based preventive dental service that will build on the child smile programme. We want all children to have the best possible chance of growing up with good teeth and we want to reduce the number of extractions and fillings that they must endure. After the debate, I will write to Jamie McGrigor about the issues that he raised with NHS dentistry in his area.

The single most pressing issue that we face is tackling health inequalities. Scotland has reversed some of the long-term trends on cancer, heart disease and strokes—several members referred to that—but the health gaps between the best-off and the worst-off are widening. We will build on what we already know about, such as the experience of the keep well programme, under which more than 8,000 health checks have been carried out so far. Later this year, we will extend the keep well service to parts of Fife, Aberdeen, Ayrshire and Glasgow and Clyde. I acknowledge the issues that Duncan McNeil raised about access to primary care services, which we take on board.

Does the minister acknowledge the issues to the extent that the Administration will move quickly to achieve not just equality of access, but equality of outcome for deprived people?

I assure the member that our approach will be outcome based. I am pleased to have been asked to chair the ministerial task force to steer cross-cutting Government activity to tackle health inequalities and to engage individuals and organisations outwith the Government in that work. I assure Sandra White that such work is intended to be outcome focused. We will get moving on that quickly.

In delivering my responsibilities, I want to bring a new emphasis, energy and enthusiasm to public health. We will start with health protection legislation, which will update provisions, some of which date back to the 19th century. We will also offer women the best possible protection from cervical cancer by introducing, from autumn 2008, a new vaccine against the human papilloma virus.

The Parliament should be proud of its track record on health improvement through reducing smoking rates. Parliamentary consensus—we almost had consensus, with one exception—was crucial in delivering landmark legislation. We have developed the proposal to raise the age at which tobacco can be purchased to 18.

I hope that we can harness the spirit of co-operation and consensus in tackling what I believe to be the next health improvement priority: alcohol misuse. Working jointly with justice ministers, we are taking action to clamp down on underage alcohol sales. Communities are right to demand action against binge drinking and the associated antisocial behaviour. We also share a wider concern about the shocking rises in alcohol-related deaths, to which Mary Scanlon referred. We must be concerned about the large proportion of the adult population, across all socioeconomic groups, whose alcohol consumption regularly exceeds the recommended weekly limits. We must address our excessive drinking culture. That is the problem not of a small minority, but of us all. Collectively, we consume too much alcohol. That position is the starting point for our action.

Does the minister acknowledge the problem that 100,000 children in Scotland live with a parent who has an alcohol problem?

I very much acknowledge that, which is why I ask for the Parliament's help in leading a new debate about Scotland's relationship with alcohol and what we should do to tackle it.

Mary Scanlon mentioned good mental health and well-being. We acknowledge that issue and our focus will be on early intervention and prevention. We will produce more information on that in due course. I acknowledge Angela Constance's reference to mental health and the expertise that she brings to the Parliament. She also talked about car parking charges at St John's hospital, which I will look into.

The Government has—rightly—identified a healthier Scotland as one of its five strategic objectives. That lies at the heart of releasing Scotland's latent potential as a nation. Sustaining and improving health will also depend on Scots changing their behaviour, whether through changing their diet, taking exercise or changing their smoking or alcohol consumption. The Government will encourage and support people to make those changes. Today's debate is only the beginning. I look forward to working with the Parliament in our endeavour to create a healthier Scotland.