Good afternoon. I welcome committee members and witnesses to the 15th meeting of the Health Committee in the second session of Parliament. I have received no apologies and I remind people to switch off their mobile phones and pagers.
Are there buttons that we have to press if we want to speak?
No, please just indicate that you want to speak.
In general, the BMA welcomes the changes and reforms that are proposed in the bill, although we would particularly like there to be greater emphasis on certain areas. The BMA is keen that inter-health board working should be pushed quite hard, as we believe that, although Scotland will continue to have 15 health boards, there is great opportunity in a country of some 5 million people to work across health boards through managed clinical networks to develop services that are appropriate for the populace.
The Royal College of Nursing Scotland supports the reforms in the bill. Some of our concerns are probably operational. We are concerned that nursing, nurse leadership and nurse executives should be in position in the levels underneath the boards, but that is not necessarily a matter for legislation. In general, however, we support the commitments to the integration of services at an NHS board level that will be brought about by the reforms.
We broadly welcome the reforms, which will improve service delivery through better integration. We are slightly concerned that training and education are not given a high profile as they are integral to better service provision. We would like more emphasis to be put on the integrated approach to training and education, and for NHS Education for Scotland to be brought into that equation.
I thank you all for your written submissions, which we have before us.
What do the three groups of witnesses think of the treatment of service delivery in rural and remote areas? Do they have any views for or against it, or suggestions that we should listen to?
Your question is valid, but I hope that the dissolution of trusts and the focus on the health board area, the other reforms such as the establishment of community health partnerships as vehicles for service delivery in remote, rural and island communities, and the linkages between health boards that have been mentioned, will be among the routes to secure improvements and integration of service design and delivery in remote, rural and indeed urban areas throughout Scotland.
My question was on the back of the convener's, in that the bill talks in generalities about health boards as if they were all unique models. We have received indications that there will be problems in some areas. There have been comments about inter-board area working, which has obviously been accepted by the college and the BMA. I wondered whether, at this early stage in our discussions, you had any other comments about the roll-out of services in those areas.
It is important that the need for local flexibility in service delivery is recognised. The arrangements for service delivery in the remote communities have to be significantly different. Although we want to maintain standards of care that can be delivered locally, there are issues to do with the availability of staff that mean that local solutions are required and there has to be flexibility. One hopes that the new health boards will take that into account.
On the abolition of the trusts, first, do you think that the proposed operating divisions in the NHS boards are the right structure? Secondly, do you think that the aim of reducing bureaucracy will be achieved as much as it should be with the removal of the trusts or should the opportunity have been taken to reduce bureaucracy further and ensure that there is a more streamlined management structure?
If you are asking us whether the BMA would have favoured having fewer health boards, we have probably said in the past that we would. However, that has to be balanced against the risk of introducing major upheaval throughout the service in Scotland. There is clearly no appetite for that.
It is important that there is clarity of responsibility within the new health boards. In the old trust structure it was clear who had responsibility for quality of care. It should be made explicit in the bill who has direct responsibility within the health board structure. So long as there is clarity of responsibility and accountability, the operating divisions should be able to function correctly.
We make clear it in paragraph 5 of our submission that our members have said that they are seeking
I reiterate that, at ground level, there is concern about the impact of another change in management structure. It is important that that is done relatively seamlessly. In the longer term, there may be a saving on bureaucracy, but it has perhaps not been recognised that there will be a transitional cost.
You mentioned the obvious opportunities to tackle the bureaucracy in the management system by bringing people together and so on. Below the managerial level, in front-line services, what opportunities will the new structures open up for greater flexibility for clinical staff to deliver services? How will the bill improve the cross-board working that has increasingly become necessary to deliver services?
By introducing a duty on health boards to work across their boundaries. That will ensure that when they are moving and developing services, they will look at what is happening in the boards around them. There will—hopefully—be a more seamless development of services that takes into account the needs of patients outwith the board area.
We are going to move on to that in due course.
I am happy to come back to that. Is there not a requirement on boards at the moment to work together for the benefit of patients? If there is, why has that not worked effectively? What will be the effect of the bill making that an imperative? We see boards protecting their budgets. Are you confident that you will receive a realistic and positive outcome as a result of what seems like an increased duty?
My understanding is that boards have not been under any statutory duty to co-operate. They have obviously been under a moral duty to find out what is happening around them, but stipulating in the bill that boards must work together means that when developing a service they will have to think about, for example, the area to the west or east of them as well as their own patients. They will have to consider the commonality of area instead of concentrating on their own silo. I hope that such an approach will avoid a situation in which services that are developed in different areas are in competition because they are responsible only for the patients within a particular boundary.
Will that in turn encourage a culture within the present trusts and among clinicians in which they can work effectively together? After all, although we can give some good examples of networking and of clinical networks that have been established, we know of bad examples within hospitals where people do not co-operate with those in other disciplines.
Before the document "Partnership for Care" and the draft bill were published, much of the discussion on this matter centred on the issue of removing competition. In Scotland, we seem to be heading towards the removal of competition. I realise that we are including other aspects of performance assessment, but down south they are moving towards a system of competition that we certainly do not favour. It is not in patients' interests to have a system that does not have to take account of patients in other parts of the country or other health board areas, or that allows two trusts to compete with each other even in the same patch over the provision of services to patients. In that sense, the bill's direction of travel has got to be a good one.
Pat Dawson has been very patient. I know that she wants to comment on this matter.
The acute services review report best described aspirations with regard to working together across health boards. Indeed, one of its first sentences refers to considering the NHS in Scotland without any boundaries. Such a statement recognises that there are critical masses of service provision in small, medium-sized and large areas and indeed in areas beyond Scotland's borders—that is, south of the border. I agree with colleagues who have suggested that, in its requirement to have cross-border working, the bill represents the final aspiration. Whereas the issue previously centred on cross-border finance flows, we will now have a very helpful requirement to carry out cross-border planning.
Dr Watson, it is important to return to a comment that you made in response to an earlier question. I think that you said that a transitional cost might be associated with the dissolution of trusts. However, there could be problems in that respect, because the Executive has said that the bill is cost-neutral and that it will have no cost implications. Indeed, it has said that any savings from the reduction in costs will have to be used to improve patient care. Presumably—[Interruption.]
Shona, I have to interrupt you, because your microphone is pointed away from you. The people in the recording room are semaphoring at me.
Sorry.
The answer depends on what time scale you are talking about. There are potential cost savings in the medium term, but if they are to be achieved, investment will be required in the initial phase of change. Over a longer spread, money should be saved but, unless we prime the management change properly, it will be increasingly difficult to implement the bill effectively, which will mean that savings will not be made. In the past, the tendency has been to underinvest in change, which has meant that the outcome of the change has delivered less than was expected.
Are you saying that the Executive is wrong to claim that the bill will be cost-neutral?
No. The issue depends on the time scale over which the Executive is saying that the bill will be cost-neutral. Over a five-year time spread, the bill may well be cost-neutral and money might be ploughed back into patient care, but it will be difficult to implement the bill at zero cost in the first year.
The Executive says that that will happen, but you think that it may be difficult to achieve. Are you worried that the resources that are required may have to come from within existing budgets?
There is a risk that the rate of change will be limited by resources and therefore that longer-term savings and reinvestment will be more difficult to achieve.
I want to return to the issue of relationships between boards, such as managed clinical networks. The idea implies that money will follow the patient, but boards that are under pressure, in part through the Arbuthnott formula, might have difficulty in providing care for patients in other areas. Within the new structures—if you accept them—do you want a system in which money follows the patient and in which boards are under a duty of uptake if another board has the capacity to provide a service that they do not provide?
Who will answer first? Just go for it—he who dares, wins.
We do not advocate a system in which money specifically follows the patient, although we advocate collaboration in the provision of services. If a health board can potentially provide a specialist service to three health board areas, it would be ridiculous if that board were constrained because of a lack of collaboration between the boards. We do not envisage that collaboration will be on an item-of-service, named-patient basis, although collaborative planning between health boards will be required. It will have to be recognised that, particularly with specialised services, health boards can provide services for populations of patients that are larger than the populations in their areas.
I asked the question on the back of your comment that you do not want the NHS board boundaries to change. If we focus on the opportunity for service delivery, more out-of-area payment systems will have to be set up, which will be a paper chase. I ask you to go beyond that stage and say whether money should go from one board to another. Boards may be under a duty to set up services for other boards, but it appears that they will not be under a duty to send patients to other areas, as long as they meet the Government of the day's waiting-time targets.
I do not think that the two are mutually exclusive. A board may provide services for patients with diabetes in a wide area. The planning of that service will require collaboration and perhaps rationalisation of funding. However, the situation may be totally different for another service. That is the system that we advocate, rather than a system that is focused on individual patients travelling in buses in one direction or another.
My answer is partly in response to Mr McNeil's question. The impact of the working time directive and the consequent need for service rationalisation will result in a lot of intra-health authority reorganisation and in movements across board areas. A formula for resource transfer will be essential because, particularly for rural and remote communities, specialist services will inevitably be provided in other health board areas. For certain services, there might be a single unit for Scotland. A smooth system of transfer of resources will be essential in that situation.
You have already mentioned community health partnerships, which are obviously an important part of the bill. The specific details of those proposals are still quite sketchy. Are you assured that community health partnerships will lead to an improvement in service delivery?
I will start off. I declare my interest—I have a day job as a general practitioner.
Yes, your name-plate says "Dr John Garner", although I have difficulty reading it, because of the angle that it is at.
I am sorry—I will give it a wee twist.
My eyesight is also at fault.
We welcome the principle of community health partnerships, but we must recall that local health care co-operatives—the organisations from which they will evolve—are relatively young; they have been around for only four or five years. A lot of work has been done in LHCCs and the BMA is concerned that the developments that have taken place and the networking, the inter-practice working and the community working that have been achieved should not be lost as a result of the development of CHPs.
I agree with most of what you have said. Some local GPs have raised with me the fear that, because the community planning process within which it is envisaged that CHPs will work involves a large number of agencies working together but is in effect driven by local authorities, the work of CHPs—from an ex-LHCC point of view—might be subsumed by the community planning process. Do you have any views on that?
That is very much up to the GPs. We do not want the creation of CHPs to result in GPs disengaging from the process. That fear exists, because GPs will no longer be at the core of things. The BMA obviously wants to encourage GPs to get involved in, and to work with, CHPs, but there is a hurdle to overcome. That is why I am not keen on a revolution from LHCCs to CHPs, but would prefer more of an evolution that builds on the strengths of LHCCs.
Would you like any specific measures to be included in the bill that could go towards ensuring that people on the health side—not just GPs but other health professionals who are involved in LHCCs and who will be involved in CHPs—will benefit?
What is in the bill has a very thin structure—or rather, it does not contain a lot of detail. The detail that emerges from the consultation process that has gone on will need careful examination to determine how matters can be progressed.
Do any other members of the panel wish to come in on that?
We would like more explicit reference to be made to consulting communities under sections 5 and 6. We would also like explicit reference to be made to staff governance, including staff representation and arrangements for staff consultation. We would like the wording to be a bit stronger and we want reference to be made to professional advisory networks.
That is helpful. Thank you.
I want to ask a supplementary. Paragraph 2.7.7 of the BMA's submission states:
From our point of view, LHCCs are financially supported by the primary care trusts—the money is devolved down. The extent of devolution from primary care trusts has varied throughout Scotland. That has given some LHCCs opportunities to develop, but others have felt that they have been constrained by the lack of resource that has been devolved to them.
Would that be better done through the regulations or guidance?
I think so, yes.
The minister will hear what you are saying.
We have to think long and hard about the capacity of primary care at the moment. As the committee well knows, there are major changes happening with the implementation of the general medical services contract. We also have ambitions to implement "Agenda for Change" in primary care, especially for our practice nurses. There is also the reform of the structures that support primary care.
It is the pebble in the pool.
Absolutely.
I will deal with public involvement, which is covered in sections 5 and 6. Section 5 will insert a new section 2B(1) into the National Health Service (Scotland) Act 1978, which makes it clear that
The RCN in Scotland believes that the committee must ask and decide whether it believes that the new structures will provide and promote independence.
I understand that independence is the key, certainly to local advisory councils fitting into the local and national system, but I am more interested in the duty of public involvement being given to the boards, as I have not heard about that. Surely, any organisation—I include your organisations—must have responsibility for public involvement and that responsibility should not be hived off to somebody else. Surely that is the key element of the bill. I would like you to comment on that matter, as I have not yet heard comments about it.
How much better might things be if there was a duty on boards and a duty to have an independent voice to represent the public? Why should the baby be thrown out with the bath water? If everything is to be done internally and there is to be a duty on the NHS to consult, we should consider the consultation processes of 20-odd years ago. In 1976, the health councils had rights and responsibilities vis-à-vis consultation processes. Indeed, the evidence that the local health council collated gave people a voice to speak directly to the secretary of state, who made decisions about whether service closure or redesign would be promoted. In essence, that structure has been changed, but what I have said indicates that, hitherto, our systems have promoted an independent patient voice at the highest level. In the bill, there is no route other than for the NHS itself to say that it has consulted and followed good practice and it either agrees or does not agree with the public. It is difficult to see how an independent external body will be able to challenge the board or be a vehicle for the voice of patients or the public.
I have another question, as the issue is important. Correct me if I am wrong, but I believe that, under the current system, local health councils are appointed by the health boards, so where does independence come in?
For many years, the health council movement has sought to reform that situation—I say that as a past director of the Scottish Association of Health Councils. It seems that we have gone for a complete overhaul and have not kept the key components of health councils' success. By virtue of there being one or two areas in which health councils recognised that it was not clever for statute to have the board appoint them, we will no longer have them—the board will be it. The duty will be on the board to do such work, with advice from an independent panel.
I share your views, but want to progress matters a bit. Obviously, independence is a crucial element, but there are also basic roles and functions that a patient expects at a local level. I am not clear about something and wonder whether you are clear about it. Who will provide the local point of contact for a patient who wants to be guided through the complaints system, for example, or who wants to bring to the attention of the local council—as they currently would—a concern at a local hospital that might lead to a walking-the-ward situation, which has happened unannounced on a number of occasions? Can you think of an alternative organisation that could provide that point of contact or a way of providing it? That element seems to be totally missing from the bill.
In the past, one of the shortcomings of local health councils was that they did not have a statutory duty to support complainants, although many did—local health councils in Lothian, Glasgow and elsewhere had high standards of complaint support. In the past five to ten years, several other agencies have sought to support individuals in making a complaint. Those agencies are primarily advocacy and other mental health, learning disability and support services. Their involvement is to be much welcomed. Another crucial organisation that has supported complainants is Citizens Advice Scotland.
There has been quite a lot of discussion about the role of NHS Quality Improvement Scotland and about which departments and functions it will take over. I recall that that was a hot topic at the General Medical Council conference.
I think that there is. We are concerned about NHS QIS's numerous functions. Standard setting is crucial, as is the inspection and monitoring of those standards. To add to those roles identifying and dealing with service failure and dealing with patients involves a blurring of responsibilities. On service failure, identification is important, but there should be a better, separate mechanism for dealing with it. The public perception is that NHS QIS is a single body and the independence that the public would welcome is not there.
We welcomed the fact that several organisations were brought together under the NHS QIS umbrella, because too many organisations were doing too many things and there was overlap. However, as we said in our evidence, the challenge is for a single organisation to fulfil all those functions. There needs to be considerable discussion about how that will be delivered at the end of the day. There is nothing in the bill to prevent us from proceeding in that way, although there are issues about the abolition of local health councils and the creation of a Scottish health council.
I think that you are looking at three different issues: first, the duty on service deliverers to involve patients in planning and everything else; secondly, a clear and distinct duty on NHS QIS to evolve standards; and thirdly—a factor that has not yet appeared in the bill—the question of who will deal with the complaints procedures and so on. Is that a fair summary of your remarks?
There are separate consultations, and Pat Dawson has already drawn attention to concerns that we all share about the separate arrangements at present for reviewing the complaints procedure. The Executive has responded and we are concerned about its response, but that is separate from the bill. Whether it would be appropriate to bring that under the remit of the bill is a different question.
In simple terms, do you see the bill as encompassing three different functions?
Yes, but I do not see them as being so distinctly different as you have put it. For instance, I would argue that there is a responsibility on practitioners and on organisations to demonstrate to the public that they are delivering care of an acceptable standard. I do not think that we should be waiting for an examination body of some sort to descend on organisations or on individual practitioners. We should not wait until then to demonstrate that service may be falling short of an acceptable standard.
I suspect that there is no member of the committee who has not had a postbag full of letters about NHS dentistry. Will anything in the bill support the promotion of patient rights with regard to access to NHS dentistry? Will it promote some of the European charters and declarations, to which our Government is a signatory, on promoting and protecting patients' rights?
Duncan McNeil, are you prepared to answer that or do you want to ask a question?
I shall comment on that. The present situation is not working and the health boards are not speaking for the communities that they represent and are unknown to many people in their communities. We have identified an issue. I do not believe that the current system of health councils is operating to people's satisfaction. Why else would all the various groups that are concerned with service change and the health service in Scotland be complaining? I am talking about community interests as opposed to specialist interests, which are well represented in the national health service and well represented here today.
That is not a question that can be answered fully in the time we have today. The bill gives health boards a responsibility to co-operate across boundaries on a raft of issues. If one also gives them responsibility for consulting the public on service delivery and service planning, the combination of those two responsibilities, if used creatively with an accountability mechanism through the NHS and the Scottish Executive Health Department, should at least provide a platform for people to share good practice, to learn from one another and to be held accountable. I am not sure that, at this stage of specificity in the bill, it is possible to add anything that will take things much further than that.
Some things can be achieved by their being enshrined in legislation and some are better achieved by other means. If we look back over the past 10 or 20 years, we see that significant patient involvement and responsiveness to patients' needs have come not from legislation but from patients' groups and the voluntary sector. We will have much more public and patient involvement if we give appropriate support to voluntary organisations and other groups that represent patients.
Mike Rumbles issued a challenge to your organisations, whose influence in the health service is secure. Is there a culture in the various organisations that you represent of promoting the community interest—apart from with warm words—so that the community's influence can be anything like as strong as the influence that you have as professionals? How do we bring that about? What ideas have your organisations brought to the process that we might use to encourage further community involvement?
What has happened—and what the BMA has strongly encouraged—is involvement at the level of the individual. As a profession, doctors and nurses have moved towards involving patients in consultation about their individual care. That is the prime building block from which the process must evolve. Previously, we have tried to encourage people in general practice to get involved in patient participation groups, but such groups were difficult to organise. We hope that, as the culture changes—and it is changing at the front line, as doctors discuss with patients the options for their treatment—we will be able to move forward.
Are we talking about the C-word—I mean consultation—which people misunderstand? The people whom I and other members represent come to us and say, "This is not consultation; they are not taking account of our views." Perhaps consultation is the wrong word to use for the type of engagement that we mean. The word gives people an expectation that they have some influence, which, until now, has not been the reality of consultations, which have mainly been about hot issues such as clinical or maternity services reviews. Can we really aspire to true consultation and a partnership in which the community interest can match the specialists' interests, and sometimes might even win the day? Is that too much to hope for?
Public involvement is crucial, but there is a danger that, in situations such as those that Mr McNeil describes, people might feel patronised and think that they have not been consulted. The difficulty is for the public to have a sufficient knowledge base, so that they can contribute in the way that they would like. Our organisations consider that it is crucial to contribute to public access to the knowledge base. A major concern is how the public can fully understand the issues, so that they have a basis on which to develop their views.
We moved on to that topic, but I want to return to local health councils, which will also involve consultation. The submission from the Royal College of Nursing makes strong representations on local health councils. It says:
The RCN board and members are not clear that there has been a full exploration of all the potential policy and other outcomes. The consultation did not involve or describe the roles of health councils. Indeed, it used the managerial objectives and not statute to describe what health councils do, although health councils have a statutory duty to represent the interests of the public of the area in which they are established.
I ask you to answer the other two parts of my question. If we keep local health councils for the purposes of consultation or representation, should they be directly elected?
The RCN does not have a policy position on that, but if the implication of your question is that independence of membership should be delivered, processes that deliver it are appropriate.
Do you have any views on how direct election would be done? My local health council put the proposal to me, and I asked it how we would go about electing local health council members. The argument against their being nominated by the board is a fair point.
It is an absolutely valid point. Over many years, the health council movement has sought ways to distance itself from the NHS boards. Indeed, until a few years ago—I do not know about current practice—most health councils managed the process themselves. The selection process and the guidelines that were developed post the Eckford review were all in place, so that, although the board had a formal role, the health councils delivered the nomination and appointment processes.
Before we leave public involvement, I would be interested to know whether the witnesses think that a good way of instilling or restoring public confidence would be to introduce directly elected seats on the health boards themselves.
I am not sure whether the BMA has a policy on that. My concern is that the board is too remote for the person who sits in my surgery or who is in Dr Mike Watson's outpatient clinic, even if they have elected someone to it. We need much more local involvement in consultation, rather than involvement at the board level. The people in my practice, the local clinic and the user groups for the diabetic clinic are those who need to contribute their thoughts about how the service is developed and delivered.
What do you think about directly elected places on community health partnerships?
We need to consider how we could achieve that. As we said, the trouble is that we do not know completely how those bodies will function. I have no personal problem with that, but the BMA does not have a policy on the matter.
I back what John Garner says. Local delivery is important. That returns to the point that what is put in place must work. There is no point in having elected individuals who pay lip service to the consultation process. The process will be effective only if people feel that they or their relatives are directly involved locally.
The purpose of our asking you questions is to obtain further detail about the comments in your written submissions. After hearing Pat Dawson's response to the convener's questions, I admit that I am more confused about the Royal College of Nursing's position. In its submission, the RCN says that it is right to give health boards the responsibility for involving people, but Pat Dawson's response to the convener's questions seemed to undermine the RCN's support. She has not mentioned something else in the RCN written submission, which criticises the policy by saying:
I am sorry to interrupt, but will you tell us where that is in the submission?
That sentence is at the bottom of page 4.
It is not contradictory to agree that any public service should have a duty to consult. The bill creates such a duty. Any statutory organisation that provides a service to the public and involves taxpayers' money should have a duty to consult in line with the requirements in the bill.
Do you confirm your support for the provision that places a duty on health boards to encourage public involvement?
The contrary part is whether dissolving health councils is also a requirement. As I said, I see no difficulty with all public bodies that provide services having a duty to consult.
Point III on page 5 of your submission says:
Support for a national organisation is not contradictory. A Scottish health council or whatever it is to be called is needed—we have no difficulty with that. The issue is whether that organisation should be within NHS QIS. Each submission to the committee has referred to that.
Forgive me, but I want to ensure that we get this right, because it is important that the RCN's views are stated clearly and that there are no problems. You say that it is right to have section 5, in as much as it gives the responsibility to health boards. You also say that it is right for the Scottish health council to be established. Is that right?
Yes.
What about the abolition of local health councils?
We question whether the new structures will provide the same safeguards as local health councils do in statute.
The BMA witnesses suggested that they would like more detail on when the power of intervention would be or should be used. I think that the public would like to know your opinion on that. When the public know about folk lying on trolleys in accident and emergency departments, or not being able to have hip replacements because there are not enough surgeons, or having to wait an inordinate time for cataract surgery because Gartnavel is short by one and a half full-time equivalent staff, they will think that someone should have intervened in some health boards a long time ago.
What do you enshrine in legislation, and what do you deliver by other means? We have a performance assessment framework, we have NHS QIS and we have the power for ministers to intervene. Those three issues should be seen as separate. I may have misinterpreted the question, but Dr Turner seems to suggest that ministers should have powers to intervene much earlier. I am not sure that we would agree with that. We support the idea of the performance assessment framework, we believe in the accountability of health boards and we support the functions of NHS QIS. However, we have reservations about whether one organisation can deliver all of those functions. It will be up to that organisation to demonstrate to us that it can.
So, you agree that there should be some intervention but feel that you would not intervene if you found that the staff and patients were dissatisfied. They have been dissatisfied for a considerable time and I am not sure that what we are discussing today will bring about any magical improvement unless structures and management change.
I agree that the provision in the bill for ministerial intervention will not solve the problem of patients waiting on trolleys. However, I do not think that the bill ever could do that. We will have to have a different system for that sort of intervention—a system that is much more responsive to the needs of individual patients when they are waiting in an accident and emergency department, on a ward or wherever. The culture will have to change across the system. We are achieving that to an extent, but we have a long way to go.
We certainly have. I do not think that the money or the personnel exist. It may be that the Executive could intervene by asking how money is being spent if all the checks are balances are not doing their job. Otherwise we would be saying that the Executive cannot change anything. Do I misunderstand you, or do you think that the Executive cannot do much?
It is not up to me to defend the Executive.
No, but you said that you had ideas on how the Executive might intervene.
To give a direct answer to the question, I would say that all three organisations agree that we could certainly do with more nurses, more doctors, more staff and more resources in the health service. That is separate from the discussion about the bill, but we would not disagree with Dr Turner on that.
For the committee's information, paragraph 39 of the Finance Committee's report on the financial memorandum of the bill states:
My question is specifically for the RCN, although it has implications for all professional groups that deliver health care. The RCN's submission recommends that there should be more detail on how staff groups will be consulted when services are being planned in different parts of the health service.
Yes and yes. The issue of the nurse executives on NHS boards was made clear by the minister, who required all NHS boards to include such a post. We are currently seeking clarification about two NHS boards that do not have nurse executives. There seems to be a strong evidence base that supports the view that clinical leadership in services—from nurses, doctors and others—can promote patient quality of care.
Does that apply to other clinical areas as well?
We are developing partnership throughout the NHS in a supportive and positive way; for example, through development of the partnership information network guidelines. The RCN in Scotland is pleased that the minister has recommended amendment of staff governance in the form of one of the powers to intervene. We know that that is being consulted on at the moment and we wait to see how that consultation unfolds.
Is it fair to say that you are happy that there will be nursing input at board level, but that you have concerns about the operational divisional level?
Yes.
I have not come across that before. Non-executive directors of trusts seem to be vanishing, but I was not aware that there would not be some form of management group that included all the potential professional input that exists. Do you suggest that that does not appear in the bill as you would like it to appear?
It might be that we are hearing emerging soundings from our members in senior positions to the effect that they are concerned about whether there will be sufficient and robust nursing leadership at the level below the board. We are keen to see whether that is the position of legislation, although I feel that that is another matter; limiting ourselves to the bill was mentioned earlier. We will certainly consider the matter because we have to promote and protect clinical leadership at all levels in the health service.
Can I widen that to the other two groups? I think that they might also have input to make.
From the BMA point of view, along with our colleagues in nursing, we want to ensure that there is medical leadership in the operational divisions—it is essential. I do not know whether that leadership would take exactly the same form, whether it would come from a unit medical director or a divisional medical director, but there would have to be someone there who has the administrative and strategic responsibility to implement the medical advice on how a particular division, hospital or unit is run. I agree entirely with Pat Dawson.
We are concerned that there were structures in place in the trusts as they stood before that have not been duplicated in the established health boards. I agree that it is early days and that the matter should not be enshrined in legislation, but we are concerned that clinical leadership will not be fully represented, as we feel it should be. The medical director sits on the board, but there are concerns that the full value of professional leadership will not be felt.
I have a question on the minister's proposals on clinical governance. Following an earlier committee meeting, the minister pledged to lodge an amendment at stage 2 that will place a duty on health boards and special health boards to ensure that they have systems in place for monitoring and improving the governance of NHS employees. Do you have any comments on the suitability of the proposed amendment? Will it go far enough?
A separate consultation on the proposed amendment on staff governance is under way and will finish, I think, on 4 February 2004. We are supportive of the principle that will be enshrined, which was suggested by the human resources forum of the Scottish partnership forum.
So you think that the proposed amendment goes far enough.
We are still consulting our members on that. Superficially, we are happy with the proposal, although some minor changes may be required. We are happy that the minister has accepted the principle and is prepared to include it in the bill.
The minister has also pledged to lodge an amendment that will encourage health boards to promote equal opportunities when carrying out their statutory functions. What do you feel about that and how do you envisage that the duty might be undertaken?
I do not know why I keep turning to you, Miss Dawson.
I am the fount of all knowledge.
Doctors have always deferred to nurses.
They get their best advice from us.
That statement will be used in evidence against you, Dr O'Neill.
We are not aware of the proposed amendment to which Helen Eadie referred.
The minister has stated that he will lodge such an amendment. In fact, Parliament has pledged that, in producing legislation, we will be mindful of its implications for equality of opportunity. The Health Committee is anxious to understand how you envisage health boards' being able to encourage health professionals to deliver on equal opportunities.
Perhaps on the back of the proposed amendment on staff governance, there will be a requirement on health boards to meet the staff governance standard on equal opportunities, which was published in 2002. We expect all employers in the NHS in Scotland to accept the range of partnership information network guidelines that are being produced by the human resources forum.
Will the proposed amendment be about equal opportunities for staff development?
It will apply across the range of services and to employees within the health service.
Equal opportunities issues have a key role in staff development. As I said, education and training are not highlighted as specific responsibilities, but it is well recognised that the opportunities for staff development are significantly different among different staff groups. We are in favour of a multi-professional approach to staff development that applies across the board and that gives people opportunities, although that will require resourcing. Overall in the NHS, staff development is under-resourced. I hope that NHS Education for Scotland will be able to help, but the boards also have a function.
Time is pressing, so if the witnesses have nothing to add, I thank them for their evidence, which was most helpful.