Primary Medical Services (Scotland) Bill: Stage 2
I reconvene the meeting. I will take members' guidance, but I think that I should share some information, in particular for the benefit of new members of Parliament—I welcome Carolyn Leckie, who is here to speak to her amendments. I will take a moment to go over stage 2 procedure, although I know that many members present are old hands—I hope that Duncan McNeil will bear with me. This explanation is for the benefit of people who are moving amendments and who might find the procedure difficult.
Amendments have been grouped to facilitate debate. However, the order in which the amendments will be moved and called is dictated by the marshalled list. All amendments will be called in turn from the marshalled list and will be disposed of in that order. The committee cannot move backwards in the marshalled list. There will be one debate on each group of amendments. I will call the first amendment in each group, and the member who is to do so should speak to and move that amendment. I will then call other speakers, including those who are to speak to all other amendments in the group. However, those members should not move their amendments at that stage: I will call members to move amendments at the appropriate times. If other members wish to speak, they should indicate that in the usual way. The minister will be called to speak to each group.
I will, following debate, clarify whether the member who moved the amendment wishes to press it. If the member does not wish to press the amendment, he or she may seek the committee's agreement to withdraw it. If the first amendment is not withdrawn, I will put the question on that first amendment in the group. If any member disagrees to the amendment, we will proceed to a division by a show of hands. It is important that members keep their hands raised until the clerk has fully recorded the votes. Only members of the Health Committee may vote. Any member not wishing to move an amendment should say simply "Not moved" when that amendment is called. I will give guidance if there is confusion—provided that I do not get confused.
The committee is required to decide whether to agree to each section or schedule of the bill. As members will recall, we go through each section one after the other and sign them off. I do not propose to delay any division to enable members who are not present to return to the meeting—this is the one and only stage 2 meeting for the bill.
Section 1—Health Boards' duties: provision of primary medical services
Moving swiftly on, I call amendment 1, in the name of the minister, which is grouped with amendments 4, 5, 6, 7 and 24.
I will speak to amendments 1, 4 to 7 and 24. This group—
I ask the minister to move amendment 1.
Okay, I will move amendment 1.
You can speak to all the other amendments in the group.
I was waiting for your next instruction.
I am sorry. You are required to move only the first amendment. I presume that you wish to move it.
Yes—I think that that would be a good idea.
This group of amendments deals with health boards' general powers and duties over primary medical services. I will summarise the main points of each amendment.
Amendment 1 is about a health board's power to provide services to patients for whom another health board has the duty to provide those services.
Amendment 4 clarifies the fact that ministers' power to prescribe the information that is published by health boards should cover all aspects of primary medical services.
Amendment 5 clarifies the intention that health boards should co-operate in relation to the full range of functions that are connected with every aspect of provision of primary medical services.
Amendment 6 provides for situations in which primary medical services can be provided to patients and includes provision for a health board to contract with a practice outside its area, and to send a patient to receive services outside Scotland if that is deemed to be in the patient's best interests.
Amendment 7 clarifies that such provisions will relate to any order that may be made, rather than to one specific order.
Amendment 24 is consequential on amendment 1.
I move amendment 1.
I refer members to the letter that we received from the minister and I thank the minister for it. It is not numbered among today's papers because it came in too late. The letter is dated 1 December 2003 and explains some of the amendments, which members might find useful.
Amendment 1 agreed to.
Amendment 2, in the name of Carolyn Leckie, is grouped with amendments 3 and 8.
All the amendments in the group seek to ensure that the bill provides no opportunities to contract with private, for-profit medical establishments. As it stands, the bill does not preclude a private organisation, such as a pharmacy, from expanding the services that it provides. That is happening at present. Boots the chemist is moving into primary services, and even BUPA could be contracted to health boards.
All the amendments in the group seek to ensure that there is no contracting with a private, for-profit provider. Although the Executive's statements on the guidance that it will issue to health boards give some assurance, outwith legislation, about contracts with private providers, I am a bit puzzled as to why, against a background of negotiations on the general agreement on trade in services, that has been omitted from the bill.
I move amendment 2.
I oppose the amendments in the group on the ground that they challenge current practice. Private health care providers already provide care in the national health service. For example, GPs in limited liability companies already provide services and Carolyn Leckie's amendments would wreck that provision. Therefore, I have no hesitation whatever in suggesting that the committee reject amendments 2, 3 and 8.
I also wish to speak against the amendments, although not quite along the same lines as Mike Rumbles did, despite my having some sympathy with his views. I got the impression that the aim of the bill is to improve the desirability of working in certain aspects of health care in Scotland. It therefore strikes me as rather odd to set up additional barriers to stop people working in health care. If anything, the amendments would close down the national health service as we know it. All health care is governed by legislation as to suitability and qualification, and the same procedures are followed for the education and accreditation of those who work in the health service, regardless of which sector they work in. Many of the people who end up in private health care, such as general practitioners, invest in and work in the health service, and there has never been a question as to whether they put their patients first.
Ms Leckie will be able to answer my questions when she winds up. Is it her purpose to nationalise all aspects of health care? If so, how does she envisage that being affordable, accessible or desirable? How will the transition be handled? Is she not of the view that perhaps the health service should be paid for from the public purse, as it is now, but not necessarily delivered through the public sector, because that has led to inefficiency in many cases?
Whereas I would always take the opportunity to restrict private profiteering from the health service and oppose the use of private finance initiatives and so on, I agree with Mike Rumbles's view of this group of amendments. The fundamental problem with the amendments is that they would undermine the role not only of general practitioners as independent contractors but of community pharmacies, which would fall foul of the proposal on the ground that they are privately owned concerns. However, community pharmacies are an essential part of health service delivery at the moment and will be given an enhanced role in the delivery of many aspects of illness prevention in local communities. The amendments would target them, even if that is not the intention.
It is worth pointing out to Carolyn Leckie that, in its briefing on her amendments, the BMA points out that the proposal would not restrict commercial companies' ability to provide health care, as it relates only to privately owned companies and not to limited liability companies. That shows that the amendments are fundamentally flawed.
I am not quite clear what Carolyn Leckie is trying to achieve. All of us, with the exception of David Davidson, want to restrict the ability of the private sector to expand in the national health service—
Will the member take an intervention?
I am afraid that interventions are not allowed.
We have to realise that the current set-up of the NHS, with its many elements and the relationships that it has with community pharmacies and so on, is complex and that this bill is not the place to try to amend that situation.
I will oppose Carolyn Leckie's amendments, from the perspective that the existing set-up is correct, provided that there is always state funding when contracting with any agency, whether it be a private concern, a GP or whoever. We see similar approaches across Europe. For example, Sweden contracted with Germany to undertake a range of operations that were paid for by the state in the interests of providing services to individuals. That step was critical with regard to making progress on waiting lists.
Further, the amendments would physically harm many complementary or alternative therapists, at a time when their support for GPs and other primary care services is growing. I would not like the use of reflexologists, osteopaths, chiropractors, aromatherapists and so on to be restricted. They play a growing and vital role in the health service.
I did not get a chance to consider further the detail of Carolyn Leckie's reasons for lodging her amendments but I think that we must take care when introducing private companies into the health service. Back in the 1970s, a company called Aircall used to conduct out-of–hours calls on behalf of doctors. It was keen on making a profit at the expense both of the doctors who worked for the company and of the patients.
It was nice to have an alternative—sometimes, one needs an alternative. In my case, I worked with another company that provided a doctor-run service, so there was an alternative. It was difficult to get GEMS going when it started up, and when I opted out of it, I had the alternative of going to another company that provided a different service. We need to be able to choose services and we should not be held to ransom by any of the companies that may be waiting on the sidelines to come in. I have spoken to patients, doctors, nurses and other members of staff who are worried that BUPA and other companies may well come in and fill the gaps that appear.
I will not vote for Carolyn Leckie's amendments, because I probably do not know enough about the detail, but I am thinking about my experience of situations in which private companies have helped doctors out. They were not the most expensive option and they actually delivered a better service for the patient. We must weigh up each individual case.
For the record, could you tell us what GEMS is?
GEMS stands for the Glasgow Emergency Medical Service (General Practice) Ltd. It was run by doctors and set up by the Government and the local health authorities.
David Davidson, would you like the right to reply?
Thank you, convener. I would like to respond to a comment made by Shona Robison, who more or less accused me of giving an ideological response that all things must be private. That is utter nonsense. However, if the quality of care can be delivered in a cost-effective manner so that the public purse gets value for money, we should not close our eyes to that.
I echo what Dr Turner has just said. Many years ago, when I was a young pharmacist, I operated the out-of-hours service for the northern half of Kent in conjunction with a private limited company owned by two GPs. There was no public provision for that service whatsoever; it was simply provided on a fee basis to the GPs involved. I do not want us to get into an ideological discussion of whether the only good job is done by the public sector or by the private sector. The bill is about putting the patient at the centre and ensuring that we take every opportunity to provide high-quality, cost-effective health care to the appropriate standards set by the Parliament.
As members have recognised, amendments 2, 3 and 8 seek to prevent health boards from contracting with private health care providers to provide primary medical services. We believe that the proposal is unnecessary and that it would prevent health boards from making decisions—utilising maximum flexibility—in the best interests of a patient. We believe that the quality and availability of care are important, not the nature of the provider.
We expect that GP practices will continue to provide the vast majority of care, just as they have done for the past 55 years. The bill is about improving the position of GPs and patients and about sustaining general practice, not replacing it with private companies. Under the new arrangements, existing practices will have the right to continue to provide both essential and additional services. A practice that provides those services on 31 March will not see them taken away on 1 April and given to Boots the chemist or anyone else.
Carolyn Leckie referred specifically to large companies such as Boots, and I can assure the committee that large organisations such as Boots and Tesco will simply not be able to hold a GMS contract, by virtue of the conditions in the bill that stipulate specifically the type of people who would qualify to hold such contracts. Such organisations would not fall within the range of those that would qualify.
I would like to comment specifically on amendment 3. I fail to understand why it would be more acceptable for private providers to be involved in the provision of primary services at certain times of the day than it would be at other times. That does not flow with any kind of logic. I therefore urge the committee to reject amendments 2, 3 and 8.
The contributions have merely confirmed my fears about one of the insidious purposes of the bill. I shall start with Mr McCabe's contribution. By asserting that quality and availability are the most important aspects and by talking about the "vast majority", he is obviously not ruling out the expansion of private provision of general medical services. He gave assurances about Boots but, as I understand it, the bill refers to any company being eligible to be a contractor as long as one GP is a shareholder. I am sure that Boots and BUPA could arrange that, if they have not already done so.
That takes me on to some of the spurious points that were made in opposition to my amendments. We must remember to see the amendments in the context of the bill and to bear it in mind that they amend specific phrases in the bill. The definitions of company and so on are already laid out in the bill. Amendment 8 is about any company
"whose primary purpose is the provision of medical services on a for profit basis."
Some of the concerns that have been raised are therefore red herrings.
Yes, the SSP's political position is for full public ownership of the NHS, including GP services. Members know that we lodged an amendment seeking that GPs should be salaried. That amendment is not included in this group of amendments, which seeks to address specifically the fear that the bill will allow the expansion of private, for-profit provision of general medical services.
There may be members of the committee who share those concerns, such as Shona Robison or other members of the SNP for example. If my amendments are unacceptable to them, l look forward to discussing amendments that they have lodged to ensure that there is no expansion of private provision of general medical services. Nothing has been said that addresses those concerns. I have to throw the question back to Mr Davidson, for example, who acknowledged in the stage 1 debate that he saw opportunities for the expansion of businesses in the provision of general medical services. He agreed that the bill will allow that to happen. Therefore, there is agreement that a threat exists, although Mr Davidson says that that threat is really an opportunity. I find it to be of concern that although there might be two committee members who acknowledge the possibility that the bill will allow contracting with a private, for-profit provider, I am the only person present who wants to prevent that from happening—I hope that we do not all live to rue the day. I will press my amendment.
The question is, that amendment 2 be agreed to. Are we agreed?
No.
There will be a division.
Against
Davidson, Mr David (North East Scotland) (Con)
Eadie, Helen (Dunfermline East) (Lab)
Grahame, Christine (South of Scotland) (SNP)
Hughes, Janis (Glasgow Rutherglen) (Lab)
Maclean, Kate (Dundee West) (Lab)
McNeil, Mr Duncan (Greenock and Inverclyde) (Lab)
Robison, Shona (Dundee East) (SNP)
Rumbles, Mike (West Aberdeenshire and Kincardine) (LD)
Turner, Dr Jean (Strathkelvin and Bearsden) (Ind)
The result of the division is: For 0, Against 9, Abstentions 0.
Amendment 2 disagreed to.
Amendment 3 moved—[Carolyn Leckie].
The question is, that amendment 3 be agreed to. Are we agreed?
No.
There will be a division.
Against
Davidson, Mr David (North East Scotland) (Con)
Eadie, Helen (Dunfermline East) (Lab)
Grahame, Christine (South of Scotland) (SNP)
Hughes, Janis (Glasgow Rutherglen) (Lab)
Maclean, Kate (Dundee West) (Lab)
McNeil, Mr Duncan (Greenock and Inverclyde) (Lab)
Robison, Shona (Dundee East) (SNP)
Rumbles, Mike (West Aberdeenshire and Kincardine) (LD)
Turner, Dr Jean (Strathkelvin and Bearsden) (Ind)
The result of the division is: For 0, Against 9, Abstentions 0.
Amendment 3 disagreed to.
Amendments 4 to 7 moved—[Tom McCabe]—and agreed to.
Amendment 8 moved—[Carolyn Leckie].
The question is, that amendment 8 be agreed to. Are we agreed?
No.
There will be a division.
Against
Davidson, Mr David (North East Scotland) (Con)
Eadie, Helen (Dunfermline East) (Lab)
Grahame, Christine (South of Scotland) (SNP)
Hughes, Janis (Glasgow Rutherglen) (Lab)
Maclean, Kate (Dundee West) (Lab)
McNeil, Mr Duncan (Greenock and Inverclyde) (Lab)
Robison, Shona (Dundee East) (SNP)
Rumbles, Mike (West Aberdeenshire and Kincardine) (LD)
Turner, Dr Jean (Strathkelvin and Bearsden) (Ind)
The result of the division is: For 0, Against 9, Abstentions 0.
Amendment 8 disagreed to.
Amendment 49, in the name of Dr Jean Turner, is in a group on its own.
I lodged amendment 49 because I found that many general practitioners, patients and nurses were concerned about what will happen when general practitioners decide either to stay as they are at present or to become salaried and about who will opt out of out-of-hours provision.
My practice covered the period from 7:30 pm to 8:30 am, but that might not be the same in every case—I do not know what times will be decided on. I will give members an idea of what general practitioners do at the moment: they provide cover for their patients 24 hours a day. The family doctor service is probably the most effective medical sieve. Practically all patients are seen and diagnosed there, and the family doctor decides which way they should go—whether they should be treated by the GP, whether they should move forward through the system or whether they should go to the emergency service.
At present, if general practitioners have to be away from their practices due to ill health, holidays, maternity leave, postgraduate education, another job or bereavement, it is their responsibility to replace themselves with locums if their partners cannot or will not provide cover. I assume that, if doctors decide to become salaried and opt out of providing all the cover during the day as well as in the evening, that is where the health boards will come into play. No doctor can provide cover when they are suddenly incapacitated, for example by illness, and, at present, if the situation in a practice was really bad, the health board would step in. Over the years, locums have become scarce and expensive for practices. They are a cost to practices, as they are usually paid for out of practice income.
At present, not all general practitioners do their own out-of-hours cover. In some cases, such as in small practices, the hours between 7 in the morning and 6 at night are covered, which often means that the practice covers the on-call provision from 7 in the morning until 6 at night as well as all its clinics and other work. Such practices therefore often use deputising services, but, despite that, they often work into the evening. They cannot possibly do all their own work, so they need deputising services.
In large towns, which have the choice of a deputising service, GPs who wish to do the out-of-hours service make money. There are a few such GPs, and they are able to make a great deal of money. Not every doctor in Glasgow does that. If every GP decided to do out-of-hours work, providing that service would be a small cost to the practice, but because of work loads, it is almost impossible for them to do that work.
The bill will mean that the health board will be responsible if the GP is unable to be present in their practice to cover work within the practice. Looking back over the years, I can remember, when I was in a single-handed practice, having to make 20 phone calls to get five people together to cover my work for a week when I was struck down with a flu-type illness. Likewise, when my mother had a heart attack and was dying up north, I could not get a locum, but six practices managed to cobble together cover to allow me to get away.
Perhaps members can see where I am coming from. If a practice has a doctor who is still contracted to the health board and another who is salaried, there may be an inequality in covering the hours during the day, never mind the hours in the evening. At present, doctors can work during the day and go on to work all evening. I hope that, for their and the patients' benefit, their ability to work all the hours that come their way will eventually be restricted. At present, they can do 13 hours in a practice and then work all night, and I have known doctors who have driven themselves off the motorway because they were tired or who have come into work in the morning and lain down on their patient couch to recover. That is wrong, and I would like the bill to contain a provision that prevents one doctor in a practice, who might still be contracted, from doing all the work within the practice, or other doctors from being able to continue working all the hours that they can to make extra sums of money, because that leaves patients poorly covered.
With serious situations such as the Ibrox disaster, everybody comes together and works extra hours. In the past, good will has cemented the work that has been done. However, under the European Community working time directive, some doctors will be restricted in the hours that they work, which means that, because many doctors might opt out of being salaried, extra hours might not be covered during the day. Further, because many doctors might opt out of out-of-hours work, there might not be enough people to cover those duties. If members listened to BBC radio this morning, they might have heard about the result of a poll of 3,000 doctors, according to which eight out of 10 doctors wish to opt out of work through the night. That is of concern to patients.
I may well not quite understand the proposed options. If we want to retain doctors, we have to provide them with choices—that is great. However, if in providing doctors with a choice, they are still restricted to working excessive hours, nothing will have changed from the present situation. Some doctors may work excessive hours because of loyalty to their patients and others will do so because they want to make more money.
I am not surprised that the BMA is not exactly on my side. The bill will work only if lots of different professionals work together. I worked closely with nurses and paramedic services—I could not have worked without them—but it looks as if we may well replace doctors with nurses. We must guard against that because the two are not synonymous.
I move amendment 49.
I am not clear about the wording of amendment 49, which would put a duty on health boards to provide out-of-hours services 24 hours a day. My understanding of the definition of out-of-hours service is that the core hours are from 6.30 pm to 8 am on weekdays, weekends, bank holidays and public holidays. Perhaps Jean Turner will expand on that issue in her summing up and say why it is necessary to provide such services 24 hours a day. I do not understand that point.
I am concerned about the amendment because it would restrict the provision of out-of-hours services to general practitioners. My understanding is that such services are provided by a primary care provider of some description, who may well be a nurse or a practitioner other than a general practitioner. The service involves the Scottish Ambulance Service, NHS 24 and other agencies that provide care in the primary care sector. I am not sure how Jean Turner thinks that the service would work if it were provided only by general practitioners. I am sure that, particularly in rural areas, such a system would be totally impossible and unworkable.
The amendment states that the restrictions that it would impose will not
"apply in the case of a major medical emergency."
Jean Turner mentioned the Ibrox disaster, but the wording of the amendment is loose. I would like a more precise definition of a major medical emergency. Who would decide whether an incident was a major medical emergency?
I am sorry to say this to Jean Turner, but I do not think that the amendment is exactly well thought out. There is a real danger in continually relying on your personal experience or the anecdotal evidence that the committee receives week after week—
I think that it would be fair to move on—
Excuse me?
I am asking you to speak to the substance of the amendment and not to get into personal issues.
Convener, I am speaking to the amendment—I am giving my reasons why I cannot support amendment 49.
Well, we shall see.
I do not support amendment 49 because it is not exactly well thought out.
I accept that.
The amendment is typical of what Jean Turner has brought to our discussions on the bill. For example, in her contribution just now, she gave us the benefit of her personal experience. However, that is not a sound enough basis on which we can be asked to change the law. Relying on such anecdotal evidence is not helpful and we cannot possibly agree to the amendment in its present state.
It is important to outline why we cannot agree to amendment 49. Jean Turner referred to BMA Scotland's evidence and said—I wrote down the quotation—"The BMA is not exactly on my side". I can see that; indeed, the feeling is much stronger than that. In its introduction to the briefing note that we all received, the BMA says that it
"strongly urges members of the health committee to reject"—
the amendment—
"in the name of Dr Jean Turner MSP."
The briefing goes on to say:
"The amendment, as written, is fundamentally flawed … Under the new GP contract, the practice has responsibility for 24 hour patient care unless they choose to opt out of responsibility for out of hours care."
Janis Hughes has just made that point. The BMA says that such care is not available for 24 hours a day, because it
"falls within the hours of 6.30pm to 8am on weekends, weekdays and Bank Holidays and public holidays."
The detail contained in amendment 49 is completely unnecessary and delving into it would not be worth while. The BMA also points out:
"As self-employed contractors GPs are not required to comply with the European Working Time Directive. Nevertheless, under GMC guidelines they do have an obligation to ensure that they are fit to practice. If not, they run the risk of facing disciplinary action."
I do not like the idea of accepting as a fact that our GPs are reckless and that they run the risk of damaging people's lives because of the way in which they work. If GPs suspect that other GPs are taking such risks, they can use the disciplinary procedure that is in place. That is the proper course of action. We should not try to change the law in such detail and—I am trying to choose my words carefully—in such an unfocused way.
I have some sympathy with the principles behind amendment 49. Mr Rumbles mentioned patient safety. I suspect that the patient safety aspects of the bill will be subject to guidance from the Executive when it comes to issue conditions of practice and advice to the health boards that will ultimately hold the contracts. Using the guidance from the minister and the Executive team, health boards will decide on a national basis how to deal with aspects of patient safety other than through complying with the European working time directive. For example, people in certain areas of accident and emergency, regardless of their age, will be unfit to practise after going through 13 hours of a huge emergency session. We must consider the matter on that basis. However, I understand Jean Turner's position on that issue. I am also concerned about rural and remote practices that might not receive health board support.
The bill does not deal with some details of the duty on health boards, capacity levels and so on. Much of that will be dealt with in regulations and guidance. I accept today as I did last week the minister's assurances that such regulations and guidance will be issued.
My biggest problem with amendment 49 is its wording. For example, it contains a very poor definition of
"adequate level of out of hours care".
I suspect that that matter will not appear in the bill. If Dr Turner is recommending that the bill should cover it, she should provide much greater and enveloping guidance that is based on evidence from best practice.
For those reasons, and not because of the principle of what Dr Turner is trying to achieve, I feel that I cannot support amendment 49. It was lodged at short notice, admittedly, but the legislation will last for many years and there should be adequate negotiation and discussion over matters such as the one that is the subject of the amendment. We do not know, but such negotiations may be on-going between the health boards and the various professional groups that, as far as the public are concerned, will be involved in delivering the legislation.
I, too, will oppose amendment 49, for the reasons that Janis Hughes and Mike Rumbles have touched on. I emphasise David Davidson's point about the implications for the more remote areas of Scotland. As we saw when we considered the draft regulations last week, the out-of-hours period lasts for 13 and a half hours. The amendment would mean that GPs could not work for more than 13 hours, which must include one hour's rest. That would require a minimum of two GPs in a rural area to cover a single night shift. We all know that, in the more remote areas, the likelihood of having a disturbed night is small. Health providers in those areas might find the obligation difficult to meet. The amendment has significant implications, which is why I find it difficult to support it.
I am in the same position, in that I cannot support the amendment. I pursued some of the questioning at the committee. I was searching for guidelines that protected the patients, although it may have been misconstrued that the concern was the benefit of the doctor. It was interesting to note at that point that the professional organisations had no guidelines in place, despite their argument that shorter working hours are for the benefit of the patient. That has not been demonstrated clearly—there is an issue there, which the amendment allows us to explore again. The general benefit of reducing GPs' hours is evident in the bill. GPs can opt out of out-of-hours care, so their objectives are being successfully met, but we should still perhaps consider the impact on patients.
I shall take the opportunity to explain why, after careful consideration, we have decided that the amendment should be rejected. The amendment raises an important issue and I can well understand why members would want to probe the matter to reassure themselves that there will be an adequate continuity of service. Ensuring that services for patients are of a high quality, regardless of the time of day, is a principle that we would all support. The bill places health boards under a duty to provide or secure the provision of primary medical services in their areas irrespective of the time of day or night. There is no dispute that everyone in Scotland should have access to a quality service when they need care in the out-of-hours period, but we do not think that the amendment is the way in which to achieve that.
As part of any pre-contract discussion, we would fully expect that the health boards would discuss with the provider whether they have sufficient resources to fulfil their contractual obligations. We expect that such discussions would include whether there were enough well-rested staff to cover periods on duty safely, whenever those periods might be.
On the specifics of out-of-hours cover, in order to ensure that patients can access high-quality services during the out-of-hours period, even where the local GP practice has transferred its responsibility to provide cover, health boards will be able to secure the provision of services only from alternative accredited providers, which must meet nationally defined standards. Those standards will require providers to ensure that the quality of care that they provide is not compromised by staff being tired. We think that monitoring and updating those standards will do more to protect patients than placing inflexible restraints in the bill would.
As members have properly pointed out, the amendment would mean that only GPs would provide out-of-hours cover. Many parts of Scotland already receive excellent out-of-hours care from specially trained staff, especially nurses in NHS 24. During the stage 1 debate, Mr Chisholm referred to an example in Buckie, which showed that a range of allied health professionals are involved in the provision of out-of-hours care. The amendment would put a stop to all that. We need to consider more innovative ways of providing services, particularly in remote and rural areas.
I will deal with two points that were made by Dr Turner. It is important to stress that practices, not individuals within them, opt out. The contract holder—the entire practice—would have to opt out; it is not down to one individual to make that decision. Reference was made to the BBC report on a poll. There is an important distinction to be made. GPs may express a desire to opt out of the responsibility to provide out-of-hours cover, but the same GPs, having relieved themselves of that responsibility in their practice, may still want to involve themselves in the provision of out-of-hours cover in a different way. Rather than being responsible for providing cover 24 hours a day, seven days a week, GPs may decide that they wish to take part in out-of-hours cover once a fortnight. That would be their decision. There is therefore a big difference between a practice's decision to opt out and an individual GP's decision to hook back into providing cover through another route.
I take on board everything that has been said. I am new to this game and we produced the amendment in a hurry—as is probably obvious. The phrase "out of hours" usually concerns the hours from the evening to the early morning. In general practice, however, every doctor knows that they have a 24-hour responsibility, which is a huge burden to live with on a daily basis. I have been reassured by some of the things that the minister has said. I might wish to withdraw the amendment and come back to this important subject at a later stage. The hours that, for example, airline pilots work are restricted. We all know that people's performance decreases with tiredness, which can be as bad as drinking alcohol—tired drivers can cause accidents.
I am aware that not all GPs provide out-of-hours services. I have visited NHS 24 and I must say that I was absolutely impressed by its headquarters. When money is put into a system and people are working together in good teams, they feel confident, they enjoy their work and they perform extremely well. Although NHS 24 has difficulties and teething problems, it has come on in leaps and bounds. I might return to the problem—it is a real problem—and see what crops up. Many doctors are worried about the level of cover, especially if everybody becomes salaried, as is their choice.
Amendment 49, by agreement, withdrawn.
Section 1, as amended, agreed to.
Section 2—Provision of primary medical services: section 17C arrangements
Amendment 9, in the name of the minister, is grouped with amendments 21 to 23.
I will speak to amendments 9, 21 and 22, but I would like to hear Carolyn Leckie's views on amendment 23 before I offer any comments on it.
That is a bit difficult, as she is not present. I ask you to speak to your amendments to start with and to move amendment 9. We will deal with Ms Leckie's amendment 23 later in proceedings.
I will leave that to you, convener.
This group of amendments relates to section 17C arrangements for primary medical services. Amendment 9 is a clarifying amendment; it makes it clear that other services that may be provided under a section 17C arrangement for primary medical services are not limited to services that may be provided under part I of the National Health Service (Scotland) Act 1978. The amendment removes a limitation that does not apply to other services that may be provided under a GMS contract.
Amendment 21 makes it clear that the power to require, through regulations, that payments under section 17C arrangements be made in accordance with directions of the Scottish ministers relates only to primary medical services.
Amendment 22 clarifies that the Scottish ministers may use the power in section 17E of the 1978 act to make regulations that set out the process for resolution of disputes over the terms of a proposed section 17C arrangement for primary medical services. The bill already provides for regulations to set out such a process for GMS contracts. Again, the amendment is necessary to ensure that there is parity between what can be done in respect of such disputes, whether they arise over a proposed section 17C arrangement or a GMS contract. In other words, the same protection will apply, no matter which route a practice decides to adopt.
I move amendment 9.
Do you wish to speak to amendment 23?
Not at the moment.
As Carolyn Leckie is not present, it is open to other members to move amendment 23. Does anyone wish to move it? [Interruption.] I beg your pardon, I have the wrong instructions. Amendment 23 will not be moved at the moment.
Amendment 9 agreed to.
Amendment 10, in the name of the minister, is grouped with amendments 11 to 20, 25 to 29, 50, 31, 32, 40 and 48.
The 20 amendments in the group all relate to the providers and contractors for section 17C arrangements and GMS contracts. Together, the amendments clarify our original policy intention and ensure that the bill reflects it. The amendments ensure that the categories of eligible persons with whom a health board may enter into a section 17C arrangement or GMS contract are accurate and complete and that the terminology is clear to the reader. They also ensure that the equivalents of those persons under the relevant English, Welsh and Northern Irish legislation are eligible.
I move amendment 10.
As no other member wishes to speak, I assume that the minister will waive his right to wind up. [Interruption.] I beg your pardon, David.
It is not for me to suggest that you need an optician, convener.
I am wearing glasses—that is even more of an insult.
Rather than talk about the principle of the amendments, I seek clarification on the details of two of them. First, I wonder why amendment 14 will introduce the word "may" into section 2, at page 2, line 29—I say that for the official report staff.
Secondly, the final lines in amendment 18 state:
"NHS foundation trust, NHS trust and Primary Care Trust have the same meanings".
Why is that the case, given that trusts will no longer exist in Scotland in the near future? Is the provision temporary and intended to provide some kind of regulatory framework? I await the minister's answer.
To take the second point first, that terminology is used because those bodies exist in other parts of the United Kingdom. As members know, it has been decided to abolish trusts in Scotland but, because the bill is a United Kingdom bill, it contains terminology that relates to existing situations in other parts of the UK.
Could you clarify your inquiry on amendment 14? I cannot seem to find the wording to which you referred.
In the meantime, minister, could I just clarify something? You said that this is a UK bill, but it is a Scottish bill.
It was negotiated on a UK-wide basis and it is necessary to incorporate terms that are used right across the United Kingdom.
I understand what the minister has said. With regard to amendment 14, my concern was about the following wording:
"In relation to an agreement … under which … services are provided which is entered into with a partnership, regulations may make provision as to the effect … of a change".
What is the Executive's purpose in using that specific wording?
The wording means that we have every intention of making regulations. I will have to come back to you on the use of the word "may", but I assure you that we will make those regulations.
Perhaps the word "shall" should be used, then.
Does that mean that there will be another amendment to replace amendment 14? In procedural terms, we have to deal with the amendment as it is stated today and the vote today will be based on the submitted document.
The amendment refers to a permissive power. The section allows us to have the power to make such regulations. That is why the phraseology is as it is. The position is analogous to the one in relation to the GMS contract, so they both line up.
I can accept that.
Amendment 10 agreed to.
Amendments 11 to 22 moved—[Mr Tom McCabe]—and agreed to.
Amendment 23 is in the name of Carolyn Leckie. As she is not present, it is open to a member of the committee to move the amendment. Does any member wish to move it?
If it is not moved today, does it immediately drop out of the proceedings?
It does.
Amendment 23 not moved.
Section 2, as amended, agreed to.
Section 3 agreed to.
Section 4—Provision of primary medical services: general medical services contracts
Amendments 24 to 29, 50, 31 and 32 moved—[Mr Tom McCabe]—and agreed to.
Amendment 33, in the name of the minister, is grouped with amendments 34 to 38.
The amendments in this group cover a small number of changes to the provisions governing GMS contracts. Amendments 33 and 34 will ensure consistency between section 17C arrangements and GMS contracts. By widening the wording about what any patient choice regulations might contain, amendment 33 ensures that the wording relating to GMS practices is similar to that relating to section 17C practices for primary medical services. That is in keeping with our commitment to protect the rights of patients whatever contractual option their local GP wants to pursue.
Without amendment 34, the wording about what regulations concerning the termination of a GMS provider's responsibility to a patient might cover would be narrower than for those covering the same situation for a section 17C provider. The amendment ensures that the position will be the same for both.
Amendments 35 to 38 are designed to clarify the bill. The first is a simple amendment, which will add a clarifying "and". The other amendments in the group, by ensuring that the correct singular and plural wording is used, clarify the provisions setting out our intention that single-handed GPs, as well as companies and practices involving a larger number of people, will be able to become health service bodies.
I move amendment 33.
Amendment 33 agreed to.
Amendments 34 to 38 moved—[Mr Tom McCabe]—and agreed to.
Section 4, as amended, agreed to.
Section 5—Persons performing primary medical services
Amendment 39, in the name of the minister, is grouped with amendments 41 and 43 to 47.
This group of amendments covers changes to the section of the bill that deals with listing people who perform primary medical services.
Amendments 39 and 41 clarify the intention to provide by regulation that a performer must have his or her name included on the list for each health board that has the duty to make provision for the services that they are performing. For GPs who require to be listed in more than one area, administrative arrangements will be put in place to allow all the relevant checks on a person's fitness to be carried out by a lead board, with other boards accepting the GP on to their lists without further checks in a fast-track process. However, the overall principle is clear: to work in any health board area, a GP must first apply to get their name on that health board's list. The fact that an application to one health board has been accepted does not mean that the name is automatically included on all other lists.
Amendments 43 and 44 will remove unnecessary references to the NHS tribunal. There is no need to refer to the NHS tribunal in the bill, as separate powers under the National Health Service (Scotland) Act 1978 relate to reference to a tribunal. Proposed new section 17P(3)(h) of the 1978 act clarifies that regulations may provide for payments to be made by NHS boards to persons suspended from primary medical performers lists to protect their livelihood in the meantime. Amendment 45 removes a reference to persons appointed by ministers, as it is not intended that anyone other than ministers will determine the amount of such payments.
Amendment 46 is a technical amendment to clarify that the word "references" refers to references to the NHS tribunal. Amendment 47 amends section 29(6) of the 1978 act to include those persons on the new primary medical services performers lists in an essential definition of persons who can be referred to the discipline tribunal.
I move amendment 39.
The National Health Service Reform (Scotland) Bill, which the committee is currently scrutinising, places a duty on a health board to provide—albeit by agreement—services to patients who are not resident in that health board area. According to the Minister for Health and Community Care, a number of those services will be delivered through current primary care practices. What provision will be made in the Primary Medical Services (Scotland) Bill to ensure that that eventuality is covered?
For example, a GP who carries out a particular procedure will be included on the approved list for his health board. However, because of proximity to a boundary with another health board area, the health boards involved might agree to provide that service in the other health board area. Will the regulations establish a proper procedure to ensure that the people in the other health board area who might receive the service can be secure in the knowledge that the GP is registered and scrutinised—not just for that one purpose but for all purposes that might arise from the arrangement—in both health board areas?
I tried to say earlier that, as far as delivery of primary medical services is concerned, the GP must be registered in every health board area in which they perform those services. Ensuring that a lead board makes all the relevant checks will prevent the other health boards from having to reinvent the wheel. However, the health board in each area where the GP in question performs must ensure that it has the relevant information and is satisfied that that person is on the other board's list. If that is the case, that person can be added to the health board's list. In other words, a person who performs in a particular area must be listed with the health board in that area. Does that answer your question?
Yes, I think that I definitely received an answer.
I want to clarify some of the fine print to ensure that we do not aggravate the BMA or anyone else because they have to renegotiate a particular point. I think that the minister said that if, for example, a patient in one health board area went by agreement to receive treatment from a GP in another health board area, that GP would be registered with and scrutinised by that health board. That is fine. However, if that GP delivers the treatment in a practice in the patient's health board area, will the bill ensure that he will also have to be registered and on the list in the patient's health board area?
If a health board has a duty to provide a primary medical service, any person who provides such a service must be on that health board's list.
Thank you very much, minister. I take it that you have just wound up on that group of amendments.
Yes.
Amendment 39 agreed to.
Amendments 40 and 41 moved—[Mr Tom McCabe]—and agreed to.
Amendment 42, in the name of the minister, is in a group on its own.
Amendment 42 relates to the standards for individual performers and makes it clear that regulations may cover the standard to which primary medical services must be delivered by individual doctors. That will allow us to ensure that appropriate action may be taken when such services are not delivered to an acceptable level. The vast majority of GPs provide excellent services to their patients, but it is important for the safety of patients that the few who fail can be dealt with appropriately.
The amendment also clarifies our intention to use the regulations to continue to require doctors to make declarations and give undertakings in relation to inclusion in lists and to require them to give certain consents.
I move amendment 42.
Amendment 42 agreed to.
Amendments 43 to 47 moved—[Mr Tom McCabe]—and agreed to.
Section 5, as amended, agreed to.
Section 6 agreed to.
Section 7—Ancillary provision
Amendment 48 moved—[Mr Tom McCabe]—and agreed to.
Section 7, as amended, agreed to.
Section 8 agreed to.
Schedule agreed to.
Section 9 agreed to.
Long title agreed to.
That ends stage 2 consideration of the bill. I thank the minister and committee members.
Meeting closed at 16:13.