Rural Out-of-hours Health Care Provision Inquiry
We move to item 8 and thank the Cabinet Secretary for Health and Wellbeing for her patience. This is the final oral evidence-taking session in the committee's short inquiry into out-of-hours health care provision in rural areas.
I welcome the cabinet secretary, Nicola Sturgeon, to give evidence. She is accompanied by Frank Strang, who is deputy director for primary care, and Ian Williamson, who is performance manager of the Scottish Ambulance Service and NHS 24. I welcome them both. We will go straight to questions from members.
We heard from NHS Quality Improvement Scotland and Audit Scotland that there is a lack of quality standards and that a review was planned because patients did not know what to expect. I felt that that response was very honest and would lead to greater accountability. However, in the British Medical Association's evidence, it said that QIS has
"demonstrated that quality performance targets have been met across Scotland."
Also, the NHS Tayside submission states, in reference to Kinloch Rannoch, that the out-of-hours cover is
"within a framework that meets and exceeds the legal, regulatory and inspectorate requirements and standards".
Those are the standards that QIS and Audit Scotland say do not exist, so I am a wee bit confused.
I will try to reply to that as straightforwardly and simply as possible.
I know that the standards have been discussed at the committee's previous evidence sessions. There are QIS standards for the provision of safe and effective primary medical services out of hours—I have those standards in front of me. I assume that the committee has seen them but, if not, we can make them available.
I can give members a couple of examples of the standards that are included. Under the heading of accessibility and availability, boards have to ensure that
"Access to, and delivery of, services is not compromised by physical, language, cultural, social, economic and other barriers."
Clearly, there is a reference to geography in that. Another example, under the heading of audit, monitoring and reporting, is that boards must have in place a set of key performance indicators that cover patient involvement and clinical and organisational aspects.
Those are the kinds of things—there are many more—that the QIS standards cover. Boards also have in place a range of different performance and quality indicators that they measure their out-of-hours services against. QIS also assesses the services against those standards.
If there is an issue with the standards, it is that, although all boards are required under the QIS standards to have quality and performance indicators in place, the indicators in one health board are not necessarily the same as those in another. There are not detailed, consistent, Scotland-wide quality indicators. That means that, although individual boards can assess their out-of-hours services against their own standards, they are not necessarily comparable with those of other boards.
The other criticism—if I can call it that—that has been levelled at the QIS standards is that perhaps they are too process driven and do not focus enough on clinical outcomes. The debate that there has been in previous committee evidence sessions has been interesting and has allowed me to reflect on that matter.
I should say first that I am satisfied that boards, through their local arrangements and key performance and quality indicators, are in a position to assess the quality of their out-of-hours services. However, at this stage—six years on from the new GP contract—I think that there would be great merit in asking QIS to look afresh at the standards and to ask whether it can develop a set of quality indicators that would be consistent throughout Scotland and allow comparison between different board areas. My officials have been in discussion with QIS about that, and I intend to ask QIS over the next period to review the standards to take into account some of the comments that have been made in the committee.
That is a good point. I hope that a lot will happen following the committee's report and, if we can get clear standards, that will be a huge benefit. However, I want to put on record that Audit Scotland said that, as you acknowledged, the
"QIS standards explore the processes and procedures underpinning the delivery of out-of-hours care rather than assess the quality of services".
In 2007, Audit Scotland said that there was
"no coherent national approach for monitoring"
and enforcement and a lack of clear quality standards for out-of-hours service. It is worth putting that on record because I think, looking at patient safety and service quality, that it is slightly disingenuous of NHS Tayside and others to say that they have met and exceeded all the standards when Audit Scotland and QIS say that there are no standards. However, I thank the cabinet secretary for her response.
It is important to get firmly on the record that there are QIS standards and that boards are assessed against those standards—NHS Tayside is rated at level 4, which is the highest level—although I will not repeat what I said about the issues with the standards that have led me to think that a review of them is appropriate.
The other point that it is important to stress is that, although the QIS standards focus on the processes that boards should have in place, the boards themselves have quality indicators.
For example, boards routinely provide real-time monitoring of how they handle calls and deliver services against the NHS 24 timeframes. They produce performance-monitoring information about service costs, call demand and call disposition. They have in place procedures for investigating and learning lessons from any adverse incidents. They also have in place arrangements under which they report as part of their clinical and corporate governance reporting.
I do not want the committee to be under the misapprehension that no standards are in place—I am sure that it is not. Standards are in place but, on the basis that we should always aim to learn from experience—particularly six years into the new contract—it is timely for QIS to look afresh at the standards and to consider whether a common standardised set of clinical outcomes could be developed for boards to assess themselves against, for QIS to assess boards against and to allow comparisons between boards. For reasons that we might discuss later, that task will not be without challenges. The nature and geography of Scotland mean that, by necessity, boards deliver out-of-hours services in different ways. Nevertheless, the exercise is worth doing.
That answer is helpful and brings us to where we are today. A huge number of submissions say that patients are confused. We do not know whether patients' expectations are realistic. At Kinloch Rannoch, Murdo Fraser made the good point that an emergency response differs from the provision of GP services—an emergency response differs from clinical care.
Last night, I read a paper that I received from a Highland doctor who is about to do the four-year pre-hospital emergency care certificate, which is on top of his five years as an undergraduate and his four years of training to become a GP. This guy will have done 13 years' training in order to join BASICS—the British Association for Immediate Care. He says that, as a result of what is happening,
"there can be little experienced clinical input to a potentially ill patient prior to them attending, by arrangement, to hospital based services."
He highlights the difference between an emergency response and appropriate clinical care. We know that the first responders in Kinloch Rannoch do an excellent job, but in no one's imagination does five days' training compare to a GP's 13 years' training.
We are finding that there is an emergency response and there is appropriate clinical care. Will you explain that to us? Have we focused so much on response times by the Ambulance Service or community first responders that we have missed the question of what the appropriate clinical care is, which might or might not be from a GP? Do you share my view that those two issues have become confused in the debate?
That might be the case but, before I answer that question, I make it clear that first responders, who increasingly perform a valuable role in communities throughout Scotland, are not a substitute for a GP or an ambulance when an ambulance with a paramedic is required. First responders supplement the care that is otherwise available and provide a more immediate response when that is of value to a patient. It is important to be clear about that.
Most important of all is that, when patients access care out of hours, they are referred to and access the appropriate care for their needs. A big misconception is that NHS 24 provides out-of-hours services. It does not. Its job is to provide the call-handling service, the triage and the referral to the appropriate services consistently throughout Scotland. NHS 24 therefore has a key role in ensuring that patients are referred to the appropriate service, which is the Ambulance Service if the incident is immediate or life threatening. If the matter is less serious, the appropriate service might be a minor injuries unit, a GP out of hours, a community paramedic or a patient's GP in hours, when their GP's surgery next opens. That is appropriate. Obviously, people who know—or whose relatives or those who are with them know—that they are in immediate danger or a life-threatening situation will phone the Ambulance Service directly.
Given our geography, we will, no doubt, go on to talk about specific concerns and challenges in certain parts of the country. However, it is important that we have in place systems that refer people to the care that is appropriate to their needs at any given time, and I believe that we do.
Pauline Howie, the chief executive of the Scottish Ambulance Service, told us last week in Kinloch Rannoch that the service has had a 35 per cent increase in the number of call-outs during the day since the new GP contract was introduced and a 42 per cent increase in the number of call-outs out of hours. The service feels that it is filling the gap although it is an emergency response. When we are considering issues of clinical care and emergency response, that figure sums the situation up.
Obviously, as Pauline Howie told the committee last week, there has been an increase in demand for the Ambulance Service generally. We can debate the extent to which the in-hours increase in demand is related to the GP contract, but there has been a general increase in demand that is slightly higher out of hours. The Ambulance Service is part of a multiprofessional, multidisciplinary team that provides out-of-hours services. It is important that its role is understood and that there is clear understanding between it and territorial boards. A lot of work is going into that, particularly with the remote and rural health boards, to ensure that it is understood what the Ambulance Service is there to provide.
That goes back to my point about the need to ensure that patients have been referred to the most appropriate care. Something like 6 per cent of calls to NHS 24 are routed to the Ambulance Service for an ambulance response—that is a relatively small proportion of calls. Also, rightly, procedures and protocols exist between NHS 24 and the Ambulance Service, which are increasingly working in a much more integrated way, to ensure that, if a patient calls one of those services but they would be better catered for by the other, that call is transferred appropriately.
I am not saying that everything is perfect. As with all areas of the health service and the services that it provides, there is always scope for learning and improvement. However, increasingly, the Ambulance Service, NHS 24 and territorial health boards are working in a more integrated way to ensure that all their roles are understood, that the Ambulance Service is responding to the calls that it should be responding to and that other parts of the health service are doing likewise.
We were struck by the fact that there seems to be some friction between the services, as Mary Scanlon has suggested. The Ambulance Service says that it is receiving more calls and the health boards are criticising the Ambulance Service for not responding in time, meaning that they are having to pick up. The differences between the two services are clear in an urban area but not so clear in a rural area. We were told that an ambulance could take four hours to reach an emergency in a rural area, whereas a GP could be within 10 minutes of that person. We need to consider how services are delivered, focusing not on what belongs to whom but on the fastest and most efficient response to people's needs. If someone who is having a heart attack has to wait four hours for an ambulance, the chances are that they will die, whereas a GP could come out to them more quickly, assess the situation and deal with it, maybe by phoning an air ambulance.
There seems to be a job of work to be done. I am not sure that it is helpful that we have a separation between the Ambulance Service and health boards, as that may create barriers. Somehow, we need to join them up. We also heard that the Ambulance Service is using BASICS-trained GPs as an emergency response but that those are not the GPs who are on call for the health boards. There could be two GPs on call, covering the same area and doing the same job, but apparently not within a joined-up system. The Ambulance Service and NHS 24 do not seem to know what is going on locally, so they are not always able to deal with it. I am not surprised that they do not know what is going on because there is such a mish-mash of different things happening. Perhaps some work needs to be carried out on that.
There is a lot in there. I agree with the general proposition that we should have as integrated a service as possible. I take the simple view that the patient who requires an out-of-hours response, whether it is for an emergency or for something routine, is not really bothered about who provides it—they want to get the right response. The services therefore have to operate in that way.
A great deal of work is being done to try to integrate services better. Earlier, I referred to work being done jointly by NHS 24 and the Ambulance Service. They now have a joint medical director and they are working increasingly closely together. You have heard about co-location in Cardonald, and there will soon be co-location in North Queensferry. The increasing trend is for organisations to work together.
Possibly the most significant piece of work that they have embarked on is towards a common triage tool. At the moment, someone who phones NHS 24 will be assessed on a different algorithm and in a different way from someone who phones the Ambulance Service. There is a strong argument for a combined triage assessment. There are complications underlying that work, but it is under way.
Likewise, the Ambulance Service is working closely with territorial boards; Rhoda Grant is right to say that that is particularly important in remote and rural areas. We have the strategic options framework for emergency and urgent response, which is an agreement between the remote and rural implementation group and the Ambulance Service that tries to clarify, for the first time, the responsibilities of various organisations to provide a response in emergency and urgent situations.
I could go on about some of the other work that is under way. A great deal of effort is being spent on ensuring that the service is joined up and integrated and, from the patient's perspective, seamless.
I take the point about BASICS-trained GPs. They might not be used by the Ambulance Service to contribute to meeting response times, but they can be and often are. Obviously, their training is radically different from that of first responders, but the philosophy is about getting the quickest possible response to the patient. BASICS-trained GPs are therefore a useful resource. Sixty-odd BASICS schemes are currently in operation in Scotland at the moment, and the Ambulance Service requires to know where they are and when they are available, so perhaps work needs to be done to make that more effective.
You made the point about NHS 24 and local knowledge. We now have a local NHS 24 centre in every mainland health board, and work is being done to network the island boards as well. NHS 24 also has what is called a knowledge management system—that might not be the absolutely correct title—which aims to have accurate and up-to-date information on all available local services and facilities. If someone phones NHS 24 and needs to know where their local pharmacy is, NHS 24 aims to use that system to be able to tell them where it is and when it is open and even to calculate the mileage to it.
As I said earlier, I do not think that everything for which I am responsible is perfect and that there is no room for improvement. A wealth of work is being done to ensure that out-of-hours services in Scotland, which are good and are delivering a quality service to patients, get even better. I agree that better integration between the different parts of the service is extremely important.
I have a quick supplementary question to Mary Scanlon's question on QIS standards. When we were taking evidence on that, it became clear that rates of pay between health boards are markedly different because of the new GP contract. The BMA told us that, basically, the rates of pay are driven by market forces. Depending on where a health board is and its access to GPs, the pay for on-call services can be as little as £10 an hour, but that can go up radically to about £150 an hour. If we are considering QIS standards, we perhaps need to consider changes to the GP contract to ensure that the payments for out-of-hours services do not penalise health boards that are in those more difficult areas.
I have a lot of sympathy with that. You are referring to independent GP contractors who, in effect, sell out-of-hours sessions to health boards and are paid for that. There is no doubt that, to a large degree, market forces are at play in that. There is evidence that, because of a greater supply of GPs who are willing to offer out-of-hours sessions, a downward force is at play on some of the costs. There are variations. For example, Greater Glasgow and Clyde NHS Board has had a healthier supply of GPs and registrars who are willing to offer sessions, so the board has maintained a largely GP-led out-of-hours system, whereas other boards have gone down a much more multidisciplinary route.
There is evidence that the costs are beginning to come down because of a greater supply of GPs who are willing to do sessions. In one of the committee's previous evidence sessions, somebody—I cannot remember who—suggested that that means that there is a greater supply of GPs who are now prepared to do 24/7, as they were under the old contract. However, there is no evidence that that is the case, although there is evidence that more GPs are willing to do out-of-hours sessions. That should have the effect of driving down the costs, but I am happy to consider further the point that the member makes.
It is important that you say that, because it slightly contradicts the evidence that we received from Audit Scotland that there has been a drop in the number of sessional doctors. I cannot remember the numbers offhand, but I think that it was 1,500 and something dropping to 1,400 and something. It would be helpful if you gave us information on that in writing, because what you have said is important for the way in which we consider the contracts in general in the future, although it perhaps does not apply so well in remote and rural situations.
I am happy to provide more information in writing, but I can speculate, perhaps wrongly, on a possible explanation for that apparent contradiction. It might be that, as boards have developed more multidisciplinary models of out-of-hours provision, they have become less reliant on sessional GPs and make less use of them. However, I cited the evidence that more GPs are willing to offer sessions and that therefore the cost is beginning to come down. I am happy to consider the point in more detail and provide clarification.
My more substantive question is about community involvement. I will use the example of the experience in Kinloch Rannoch. My understanding was that the community had met the health board and reached an agreement. The job was then advertised, but what happened afterwards did not follow the agreement. How can communities interact with health boards to ensure that services are delivered in a way that suits the community's needs and meets its aspirations? Is there no guidance to suggest that, if a community and health board reach an agreement and the health board then wishes to renege on that, it should go back and consult the community? The issue is about consultation and working with people.
I will come on to the generality of that in a second, as it is important, but I am not sure that I entirely understand what you are referring to when you talk about an agreement between Tayside NHS Board and the community in Kinloch Rannoch.
My understanding is that the community agreed with the health board that it would look for a GP who would provide out-of-hours services, and that that was what was advertised. People in the community tell us that the provider that was appointed was the only applicant that was not willing to provide out-of-hours services. The agreement on the job specification should have been adhered to. If the health board intended not to adhere to that, it should have gone back to the community and spoken to people.
If I can manage to do so, I will address that point without getting too far into the details of the Kinloch Rannoch discussion, because, clearly, responsibility for the provision of its out-of-hours services lies with NHS Tayside and, as I understand it, some of the history of the Kinloch Rannoch situation predates my time in office. I believe that this case is the only time, not just in Scotland but in the United Kingdom, when a panel has been established to decide on a challenge to a GP's decision to opt out of providing out-of-hours care. NHS Tayside did not oppose the decision to opt out in principle, but it wanted the arrangement to be phased. The panel's decision went against NHS Tayside. The advert for someone to replace the retiring GP was for a GP who would do out-of-hours work. NHS Tayside made a judgment, which I cannot second-guess, that the best applicant in respect of overall service provision was the one who was chosen.
I will now deal with the generality, because it is very important not only for out-of-hours provision but for any NHS provision that there is good-quality, meaningful engagement between a health board and the communities that it serves. The QIS standards that we referred to in response to Mary Scanlon include a number of standards for patient focus and involvement. Some of what health boards are assessed against in the standards relates to the way in which they work in partnership with individuals and communities in the design, development and review of services. That indicates the importance that we attach to such work.
I know that sections of the community in Kinloch Rannoch are not satisfied with the out-of-hours provision there. We may or may not come on to some of the detail of the situation later, but I understand the concern that any local community will have to ensure that it has the best service provision possible. I made it very clear when I chaired the NHS Tayside annual review, which, like this meeting, was attended by people from Kinloch Rannoch, that I expected NHS Tayside and, indeed, any health board to continue to engage, consult and try to satisfy and address the concerns of local communities.
I asked NHS Tayside to send me a copy of its most recent community update in Kinloch Rannoch. I do not know whether committee members have seen it; if not, I am sure that NHS Tayside will make it available to you. A range of engagement is under way with the community, one practical outcome of which—I accept that it does not satisfy all the concerns of some of the campaigners involved—is that the air ambulance service and the emergency medical retrieval service are now able to land on the playing fields in Kinloch Rannoch, because the agreement of the local community was obtained and NHS Tayside purchased landing lights.
As you have heard me say many times before, community engagement is of paramount importance. If a community is not satisfied, I will usually take the view that the board has to do more to address concerns but, ultimately, there will always be situations when a difference of opinion between a board and sections of a community cannot be addressed to everybody's satisfaction. Such situations will often arise, but there is certainly a strong onus on any health board to engage on an on-going basis with the communities that it serves.
I understand that and take it on board. I know from my own casework that, when I deal with communities in my own area, trying to get health boards to listen seems to cause huge frustration. People feel that they cannot do anything to put pressure on the health board, that it does not listen and that it just ticks a box, saying, "We consulted, we called a meeting and we had a focus group." It says that it held a big consultation—such as the one that is going on in Skye—but at the end of the day it is going to do what it wants to do. People feel really frustrated that they cannot engage properly. I am not suggesting that the cabinet secretary has a magic wand, but can standards be set around health board community engagement to ensure people feel that, although they perhaps did not get what they wanted, they at least had a fair hearing and their views were taken on board?
I am sympathetic to that point. As I said earlier in relation to the QIS standards, this is an area in which local boards are expected to have processes and procedures in place that they can be judged against. It is important, although sometimes difficult, to distinguish between engagement and the outcome of that engagement. I am not talking specifically about Kinloch Rannoch—there will be many examples around the country of a health board being unable to provide a particular service that a local community would like in the way that the community would like it to be provided because the health board has to take account of the provision of services right across its area. Health boards must make judgments about the optimal provision of services across their whole area. Therefore, there will be occasions on which a community and a health board will just not see eye to eye.
That does not mean that a health board does not have a continuing obligation to consult, to engage, to explain and, when appropriate, to listen to communities. As you will know from previous decisions and comments that I have made, health boards sometimes get things wrong. When they clearly get things wrong, they should listen to local communities. However, the fact that a health board and a local community do not always see eye to eye does not always mean that the health board has got it wrong; sometimes, it just means that there is a genuine difference of opinion.
Frank Strang (Scottish Government Primary and Community Care Directorate):
The QIS standards are relevant in that context in that they require health boards to involve patients not only in the design of the services, but in expressing satisfaction afterwards. That closes the loop. Health boards must not only consult on the implementation of services, but report on satisfaction rates, and there is no escaping from that.
Most, if not all, health boards have carried out surveys of patient experience of out-of-hours services. Generally speaking, although there will be specific concerns in specific communities, testing of patient satisfaction with out-of-hours services shows that the level of patient satisfaction is very high.
Helen Eadie has been very patient.
Thank you, convener. I want to continue that thread about small, sparsely populated communities. It is difficult to monitor and, as a result, to evaluate the number of situations in which care has been denied in such communities. Last week, we heard lots of anecdotal evidence of poor outcomes for patients. The fact that such communities contain only a small number of people is not a reason for removing entitlements—that is at the heart of what we have been hearing. In every community throughout Scotland, people are saying that they should have core rights and entitlements.
I think that that was in Professor Allyson Pollock's written submission. She argued—it is a point with which I agree—that health boards should not be able to remove those core entitlements from groups without the assent of either the cabinet secretary or the Parliament and without proper consultation. However, we heard in evidence last week that the consultation stage had been bypassed and that the community felt strongly that it had never been given the opportunity to see what the alternatives and their implications were. Those of us who were at the meeting last week got the impression that that is the sort of thing that leaves communities with a bad taste in their mouths and feeling that a fundamental injustice has never been remedied.
Back in the first session of Parliament, we considered a petition about changes that were being made by Greater Glasgow NHS Board without public consultation. We then had issues with the public consultation on "Right for Fife". In those days, although the health board arrived at a decision, it was always signed off by the minister. When there is a fundamental change, communities are right to argue that the change should be signed off by a cabinet secretary or a minister. Would you like to comment on that?
Major service change proposals from a health board still have to be signed off and approved by a minister—there has been absolutely no change in that position. According to my memory, that is as it has always been; I have some experience of that as the only health minister to have overturned health board decisions that had previously received ministerial approval—I am thinking of the proposed closure of two accident and emergency departments. There has been absolutely no change to the requirement for ministerial approval.
I do not want to go too far into the history of the Kinloch Rannoch situation, but the removal of an out-of-hours GP who was resident in Kinloch Rannoch was not initiated by NHS Tayside—it is not something that the health board decided would be a good idea; there were circumstances outwith the board's control. When it advertised for the GP the board made clear its strong preference for out-of-hours provision, but that did not prove possible. There are differences of opinion about the different applications that were made, but the board made a judgment about what it thought was the strongest overall application.
On the wider point about core rights, I passionately believe that people should have the right to high-quality health services no matter where in Scotland they live. A fifth of our population lives in remote or rural areas, and we have to strive to deliver quality services. One of the many reasons why I was irritated by the recent Nuffield report was that it took no account whatever of the additional costs and staff resources required to provide quality services to people who live in some of our remotest communities.
There is a debate around that core entitlement when it comes to out-of-hours services. Increasingly, health care—not just out-of-hours care but in-hours care—is delivered by multidisciplinary teams. GPs will be a strong part of those teams, but nurse practitioners, community paramedics and staff working in minor injury/illness units are all professionals who contribute to the team.
We must challenge the notion that quality out-of-hours services are not being provided in some communities in Scotland because, given their geography, they do not have a resident, 24/7 GP. There are many examples in the Highlands of villages that rely on out-of-hours GP cover that is provided from a different village. However, it is the multidisciplinary team that really provides the quality health care. Without getting sidetracked into the situation at Kinloch Rannoch, I point that service provision there includes services from NHS 24, the Scottish Ambulance Service, the minor injury/illness unit, a community paramedic and an out-of-hours GP with a car and driver. There is comprehensive out-of-hours provision there.
I do not want anybody to suggest that I do not understand the concerns that any community will have about such matters. Of course people will feel safer if they have a resident GP providing out-of-hours cover, but we have to consider the totality of the services that are provided. Many remote and rural communities are not simply reliant on GP cover.
I totally accept what you are saying. There are many health professionals scattered around Scotland and, as we listened to last week's evidence, the point about integration, which Rhoda Grant has mentioned, made an impression on me. We were given an example of an incident that could have been attended by local GPs, yet someone 100 miles away became involved. It did not seem as if intelligence was being used, and the new technology did not seem to be working.
You have perhaps covered that point about better integration, but I will quickly mention another issue to do with cost, on which the National Audit Office did some work in 2009. In her paper, Allyson Pollock wrote that the estimated cost of running out-of-hours services was approaching £68 million in 2005-06—some years ago now—and added:
"but there has been no evaluation of the costs and benefits of the changes to OOH provision."
Is that the case?
The most recent year for which I can give you figures is 2008-09. The cost of providing out-of-hours services in that year was £70.016 million. That is an increase of 3.5 per cent on the figure that you quoted from 2005-06—it is a lot of money and a big expense for health boards, especially those that cover remote and rural areas. However, the scale of the increase suggests that boards are managing to contain the costs of out-of-hours care in a way in which some thought they would not. I hope that the updated figure is helpful to you.
It is. Tayside NHS Board claims that it would cost almost £500,000 to reintroduce the out-of-hours service. That is a huge claim, given that the initial cost of opting out of 24-hour care should be just £12,000. When such figures are put to your officials by boards across Scotland, to what extent do they dig into them, to verify those claims?
A great deal, as I am sure any board official would tell you. Instead of my trying to second-guess the figures that NHS Tayside has given to the committee, we can provide you with further clarification of them or ask NHS Tayside to do so. I am not speaking for the board, but the central point that it was making was that the cost of providing a resident out-of-hours GP in Kinloch Rannoch, rather than the multidisciplinary approach that is provided at the moment, would be disproportionate. I have seen figures that suggest that in the past year there were 22 out-of-hours GP calls from Kinloch Rannoch. That is the basic point that the board was making.
We must be slightly careful when we talk about comparative costs. That issue is important, given the scale of the NHS budget, especially in tight economic times, but—rightly—the first concern of people living in Kinloch Rannoch or any other part of the country is not how much it costs to provide services but whether services are safe and effective. I do not want to put too much emphasis on the financial part of the discussion. My concern is to be satisfied that a community anywhere in Scotland that has concerns is being provided with out-of-hours services that are safe and clinically effective. That should be the first and paramount consideration.
I agree. It would be wrong of us as politicians to tell people that they cannot have a service because of its cost. However, according to Allyson Pollock, if we extrapolated the National Audit Office's figures, the additional funding at Scottish Government or health board level for Kinloch Rannoch would be £24,000 at most. I ask you to bear that point in mind and to compare what the National Audit Office and Allyson Pollock are saying with what NHS Tayside is saying. Sometimes it can be convenient for health boards in Scotland to hide behind the argument that reintroducing a service will cost an extra £500,000, which makes everyone frightened to dare to go there. In fact, we must listen much more sympathetically to the needs of communities, based on the realities.
I take Helen Eadie's point—perish the thought. I will leave it to NHS Tayside to provide the committee with clarification of its comments about costs. However, to be fair to NHS Tayside, its decisions in Kinloch Rannoch are not based solely on cost—they are also based on its view of how best to provide a quality service in the area, given the demand that exists and so on. I appreciate that there are quite acute differences of opinion between the board and the local community. That takes me back to the points that Rhoda Grant made earlier. I expect NHS Tayside to continue to engage closely with the community of Kinloch Rannoch, to see what more can be done to address that community's concerns.
If Helen Eadie gives the clerks a draft of the question that she wants to ask, I will write to NHS Tayside for clarification, on behalf of the committee. We cannot expect the cabinet secretary to know that information. Can we move on? Helen has not noticed that I am talking to her, so we will do so. If you look away, you have had it.
Two points stood out in evidence and were accepted by most people. The ideal for the individual is to have their GP on call 24 hours a day, 365 days a year. However, it was accepted that that is no longer possible or, indeed, desirable, because GPs need time off for further education and so on.
The other point that we all agreed on was that one size does not fit all. Different rural areas have different needs. The thing that concerns me—it came to my mind when we discussed the Kinloch Rannoch situation, but could be relevant all over the country—is the slight tendency for boards to try to apply urban solutions to rural settings. We could end up with out-of-hours cover that met the basic rules that were set down but was deficient in other areas. We know that NHS Tayside officials gave their board an estimate that the cost of supplying an out-of-hours service to Kinloch Rannoch would be around £0.5 million. I am told that that is because they budgeted for four drivers and three and a half GPs. In other words, they transposed the solution for Dundee to Kinloch Rannoch. Obviously, if there are only 22 out-of-hours calls a year, a GP covering that will not require nearly as much pay as someone who works all the hours between 6 and 12 or whatever in a city.
We also know that a GP or an experienced nurse who knows the patient can cut down on ambulance use, A and E work and hospital admissions. The first responder told us in evidence that he is not allowed to cancel an ambulance request, even if he can see quite clearly that an ambulance is not required. The ambulance would have to come all the way out to wherever the first responder was with the patient because that is the rule.
Could boards be asked to try harder to find solutions that provide some form of experienced out-of-hours care nearer to where it has been provided previously? For example, could the boards explore the use of a salaried GP service or the use of an experienced nurse based in the area, which could be augmented by GPs at a much lower cost than has been described by NHS Tayside? Should we ask boards to consider the situation more carefully before discarding realistic financial options, rather than transposing services that are based on a city's needs into a rural environment?
Absolutely. I will come back to the latter point in a second. I thought that you made an interesting point by way of preamble, which is that, for most people, the ideal is to have 24/7 access to their own GP. I understand that, and most people would identify that as the ideal. However, we have to accept that times have changed. When I was younger, people always saw their own GP. Now, I rarely see the same GP twice at my health centre in Glasgow. Things have moved on.
Although this discussion is helpful and absolutely legitimate, there is a tendency to look at the pre-2004 era as if it was perfect. I have no vested interest in or brief to defend the negotiation of the new GP contract, because that happened before my time in office, but we should not forget the drivers for that change. The Royal College of General Practitioners said in 2004 that a quarter of GPs were considering leaving the profession. There were real recruitment and retention difficulties, particularly, but not exclusively, in remote and rural areas, which were seen to be in large part down to the out-of-hours obligation. There was also a feeling that GPs had to improve the quality of in-hours care. The quality and outcomes framework was partly designed to do that. What existed pre-2004 was not perfect, and we should not suggest that it was.
On your substantive point, I absolutely agree that one size does not fit all anywhere, but particularly in Scotland. That is why, although we have a Scotland-wide system for triage, assessment and referral through NHS 24, it would be entirely wrong in my view to try to design a Scotland-wide out-of-hours model. Boards should not apply urban solutions to rural situations. Plenty of boards—I cite NHS Borders as an example—have put in place innovative models using salaried GPs and nurse practitioners, and in such cases the majority of out-of-hours visits are seen to by nurse practitioners. There are good examples of models being put in place to fit particular circumstances, and that is right.
My direct answer to your direct question is that boards should be encouraged, and I would expect them to try hard, to go the extra mile to find solutions that address the concerns of local communities and, in line with my philosophy, provide as much care and response to communities as locally as possible. In practice, however, that will inevitably take different forms in different parts of the country.
Taking the Kinloch Rannoch experience as an example, although I am sure that the same thing can happen elsewhere, it seems that the board advertised for a GP who was willing to provide out-of-hours cover and asked applicants to suggest ways in which that should be done. Not surprisingly, there was not a huge response. I believe that, in a remote and rural area, the board has some responsibility to devise a scheme itself, based on the area's requirements. In some areas, GPs who have recently retired but kept their registration might well be prepared to help out. The reason why loads of GPs wanted to get out of out-of-hours provision when the new contract came along—apart from reasons to do with how little was being paid—is that they were not given help. Some GPs had to do 24 hours and, if they were ill, they were still responsible.
Do you agree that, when a vacancy comes along in a rural area, the health board that is responsible for the area should try much harder than was the case in the Kinloch Rannoch example to devise a more local professional response that allows people time off and the ability to keep up to date?
Yes. I do not know that anybody would disagree with that. It is incumbent on NHS boards to try to find the most local solution.
I do not want to go back to the NHS Tayside and Kinloch Rannoch example again, but the situation in which there was no resident out-of-hours GP was not one of NHS Tayside's making. It advertised the position, got limited applications and made a judgment about which was the strongest application overall. That does not absolve it or any other board of continuing to try to find the best solutions. If NHS Tayside was sitting here, it would defend the out-of-hours arrangements that it has in place for Kinloch Rannoch. Does that mean that it should not be open to new ideas and suggestions about how the service can be further augmented and how it can further address local people's concerns? Of course not. It should always be open to that, as should all NHS boards.
Particularly in rural areas, there should be innovation, and thought should be given to solutions that are perhaps not obvious. There are examples in other parts of rural Scotland where such innovation is delivering high-quality services. I repeat what I said earlier about first responders not being substitutes for GPs, but things such as first responder schemes are in themselves innovative ways in which to build community resilience. They provide communities with a level of service that cannot always be provided in the traditional ways that are used in more urban areas.
I just hope that you will reinforce what you say in your advice to the boards, because there is some evidence that boards will quite quickly revert to what I call the urban solution, which is easily done and which meets certain basic qualifications, whereas it is quite hard work to devise something more innovative for a specific area. If you encourage boards to make that effort, I will be pleased.
Boards will always be encouraged to do that. NHS Tayside covers both urban and rural areas, but if many boards in Scotland applied urban solutions to some of the problems that they face, they would quickly get into significant problems. The remote and rural work programme that is under way is all about trying to find new solutions and new ways in which to provide services to remote communities.
Traditionally—long before I was in this role—there was a mindset that it was too difficult to deliver some services in some remote communities, and that it was easier to close the rural general hospital and send patients elsewhere. That mindset has shifted, and the emphasis now is very much on sustaining services locally. It is not always possible to do that, and sometimes it is not in a patient's interest to access a service locally when they would get a better service somewhere else. However, I believe strongly in the presumption of local delivery.
Ian McKee raised the point that first responders are not in a position to cancel ambulances. Do you have any comments on that? I think that the issue has been raised with the committee.
It was raised in evidence.
I am happy to look into that.
Would Mr Williamson like to assist?
Ian Williamson (Scottish Government Primary and Community Care Directorate):
I suspect that that is the case with first responders, and that it has been considered as being in the best clinical interests and as constituting best clinical governance. It minimises a perceived risk in those few circumstances in which the community first responder might otherwise take the option to stand down the ambulance and their judgment turns out to be wrong and something goes wrong. It is undoubtedly risk averse.
I understand the reason; I just wanted to explore the point.
I was not saying that it was wrong, but that it happens.
The point was about the use of resource.
Yes.
All these systems are risk averse to a great extent. I am aware from previous evidence to the committee that some people from the Scottish Ambulance Service think that NHS 24 systems are too risk averse and often lead to people being sent ambulances. The systems are risk averse, especially when telephone triage is involved, because we want to minimise the risk of the wrong judgment being made.
Ian McKee made the point about reinforcing some of what I have said with health boards. I do that routinely with committee reports, but I will ensure that boards pay close attention to the report that the committee produces from its inquiry, and that they discuss any suggestions or ideas that arise from it.
We have already discussed GP out-of-hours services this morning, and some of the evidence that we have received suggests that the reluctance on the part of some GPs in rural areas to participate in out-of-hours services is potentially to do with the financing of those services. It has also been suggested that some GPs in rural areas are not prepared to take up out-of-hours sessions because of the associated risks. Those are clinical risks—for example, GPs may be presented with a case but may not have the necessary clinical skills or back-up to deal with it in a particularly remote area. If NHS 24 refers someone in a city to an out-of-hours GP service, the GP may make an initial assessment and refer the person on—to the sick kids hospital, for example, if the patient is a child—for a specialist assessment. The hospital may be only a mile or two down the road in that case. A GP who is working in a remote and rural area, however, does not have that luxury, and may not have the clinical skills to make a clear judgment on the case.
One concern that has been raised is how we can equip GPs in that situation to be more confident in taking up out-of-hours sessions. That does not necessarily mean that they should be BASICS trained, but—as some witnesses have suggested—there are technological ways in which boards could address such problems. That could involve telehealth or other ideas that would help to give clinical back-up to GPs in such situations, so that they could access a specialist for advice without having to refer someone on. It may otherwise take someone a two, three or four-hour drive before they even get to the hospital where the specialist works.
That is an important point. We must ensure that those GPs and other clinicians who are working in rural areas, with all the associated issues, have the right training and back-up. A big thrust of the remote and rural strategy is how we train people who work in remote areas differently to equip them with the right skills. A lot of emphasis is placed on what are called obligate networks, to make it clear what other boards are required to do to support the work of rural health boards and the clinicians who work for them. NHS Education for Scotland has an education and training framework for non-medical professionals who work in out-of-hours provision, to ensure that they have the right skills and competencies to do that work.
Michael Matheson's general point is well made. I am happy to look at whether NES or the boards could do more to support GPs who might be keen to contribute to the provision of out-of-hours services.
What struck me from some of the evidence that we have received is that the problems that we are discussing are not new—they have been around for a long time, as have the concerns of GPs in the areas in question. My concern is about the pace at which some of the changes take place. When technological routes exist that could be used to address such concerns, it seems to take a considerable length of time for health boards to adopt them. I understand that testing is sometimes required, but I think that the communities that are concerned about the services that they receive would like to see health boards stepping up the pace at which they introduce some of those measures. To go back to what Mary Scanlon said, it is not just about someone turning up; it is about people receiving the right clinical response. We must help to ensure that people get the right clinical response as quickly as possible.
I know that the committee is extremely interested in telehealth and thinks that we should move more quickly to apply and put into more widespread use the telehealth solutions that are piloted or trialled. That is a fair point. The fact that the Scottish Centre for Telehealth is now under the aegis of NHS 24 may help in the application of telehealth solutions to out-of-hours care; indeed, that was one of the drivers for the decision to merge the two organisations. Progress is being made that will mean that telehealth will become more of a solution in some of those areas. I accept the committee's view.
On the other hand, we should not underestimate how much progress boards made on out-of-hours services between 2004, when the opt-out for GPs came in and it became boards' responsibility to provide such services, and 2006, when some of the early challenges and problems had been resolved. The NES training framework is a key example of that. Real progress has been made on out-of-hours provision and boards deserve a lot of credit for that, but we need to ensure that we continue to build on that and that new solutions—telehealth solutions, in particular—are applied appropriately. As in many other areas of service delivery, telehealth can radically reform our ability to provide services in some of our most remote communities.
Before we get into telehealth in more detail, I remind the committee that we will consider our draft report on the clinical portal and telehealth next week. That is timeous because although we will produce two separate reports, they will be strongly interconnected.
My question is on telehealth because, as the convener said, there is a link to our work on that. There are two aspects to telehealth. One is the additional connectivity that it can give the entire team in a rural area. I would like us to think beyond the box. We tend to think only about NHS staff, but in more rural communities there are sometimes police and fire service volunteers who are partially trained in first aid. We still tend to think in silos, but we need to adopt a much more comprehensive approach.
On separating out the emergency response, the military is another group that we should be thinking about and which we can learn from. The field force work that is being done at the moment is truly staggering, and what paramedics do under direction from a doctor in the base camp is amazing and life saving. We should not ignore the potential for learning from that.
The second issue is e-care. We should consider what is being done in a number of areas—we heard about that in our other inquiry. In rural communities, much closer monitoring might prevent the readmission to hospital of people with relapsing conditions. It is about ensuring that the boards focus attention on individuals who require ancillary care. That will give them and their carers confidence, and it will give them access to a centre by telelink. It is about learning from Dr Ferguson's rural accident and emergency work in Grampian and extending that to the e-care system. All those measures would give communities greater confidence.
I welcome the cabinet secretary's general response to the issue of standards, which are generally to do with processes. I am pleased that she is considering how that can be moved on. The issue is not easy; indeed, it is extremely challenging. However, it is worth while our considering moving beyond that issue to get boards to concentrate on how they can deal with things in remote and rural settings, which may be slightly different from central areas.
I agree strongly with everything that Richard Simpson has said. As he mentioned the military, I will unashamedly take a wee diversion. I pay tribute to 205 squadron, which I visited in Glasgow before Christmas. It is currently running the field hospital in Camp Bastion in Afghanistan, and is doing a fantastic job. I am sure that everybody is proud of it.
It probably should not have taken so long into the meeting before Richard Simpson's first point was made, because it is fundamental. We are talking about the NHS, which is important, but it is part of a much bigger picture. When we talk about out-of-hours services, we cannot ignore social care services, the police and fire services, and all the agencies that have a part to play. In their out-of-hours models, many boards are increasingly looking to the linkages not only between NHS professionals, but between the NHS and other agencies. That is a fundamentally important point that we tend to forget when we talk about the NHS. Richard Simpson is right about that.
The points that have been made about e-care are hugely and fundamentally important. In a sense, it makes the link between out-of-hours and in-hours provision. One of the drivers of the new GP contract was the need to improve the ability of GPs to provide good-quality, anticipatory care in hours for people with long-term conditions and therefore to make it less likely that they would require out-of-hours or emergency care. Boards that pool together their out-of-hours services are thinking, and must continue to think, about how more anticipatory care, e-care and e-health solutions have a big part to play in that, as they do in many other areas. That anticipatory care, which prevents people from having to rely on out-of-hours provision, is incredibly important.
I do not know whether I need to say anything more than that. I endorse the points that Richard Simpson made.
I think that, in general, the committee thinks that we need to get momentum behind the matter, because there has not been the push to move forward with the relevant technology over many years in the Parliament.
It is early days. I have previously heard committee members' comments on telehealth, some of which were well made. The placing of the Scottish Centre for Telehealth into NHS 24 gives us the chance to up the pace. I hope and expect that that will happen.
Ross Finnie wants to say something, and Mary Scanlon and Rhoda Grant have short supplementary questions, if they can still remember what they are. I am sure that they can.
Michael Matheson made one of my substantive points, but I want to press the cabinet secretary. We have discussed a lot how we ought to move on and stop discussing whether we should go back from the current GP contract. The person from the BMA to whom we spoke a few weeks ago puzzled us greatly because he kept referring to this ideal standard of 24/7 availability but then said, "Of course, we can't have that," which did not help the general debate.
We all understand that the GP contract was necessary, for the reasons that Ian McKee outlined, but it nevertheless had an unintended consequence of creating a lack of flexibility, particularly with regard to the need to address services in rural areas. A lot of the evidence from Highland, Tayside and the Borders pointed to increasing use of salaried GPs. That sounds excellent, although there is obviously a cost attached to that. The decision about whether to use salaried GPs is up to individual boards, but is there any policy issue around that with regard to how that practice relates to recruitment and so on? Is it to be generally understood that, for those who might wish to pursue a career in general practice, the issue of an increased use of salaried GPs is very much on the agenda?
The issue is on the agenda in all board areas. Although the majority of primary medical services continue to be provided by independent contractor GPs, and I do not see that changing, boards have the ability to employ salaried GPs to give them flexibility where they consider they need it. Some boards, such as NHS Borders, have opted to use that flexibility in relation to out-of-hours provision.
It is for local boards to make local decisions on the appropriate balance, but there is no doubt in my mind that the ability to employ salaried GPs—and salaried dentists—gives boards added flexibility in terms of the provision of services. That is a flexibility that they should have.
Helen Eadie asked my planned supplementary question but, given that I had a reserved slot, I made up another one.
There is no need to be inventive, Mary.
On our last day of evidence taking on this issue, I thank the Kinloch Rannoch community for leading us into an interesting inquiry from which I have learned a huge amount. Whatever recommendations we make, I am sure that they will be of benefit to people across Scotland. I trust that we will have a parliamentary debate on the issue.
The Scottish Ambulance Service submission summed up the issue for me when it said that
"the public and patients are confused about accessing care"
and stated:
"There is also some evidence that accessing care and advice out-of-hours is more convenient for patients".
That led me to think about how confused the public are. I invite the cabinet secretary to outline the circumstances under which people should call A and E, an ambulance, NHS 24 or a local doctor, if there is one.
I will let you answer that, cabinet secretary, but I suspect that you will not write a handbook.
I do not think that the public are confused at all. However, there is a serious point around the need to ensure, as far as we can, that people access the right part of the service, as that is in their interest.
Before I deal with that, I, too, pay tribute to the people from Kinloch Rannoch who are with us, and their colleagues. I am absolutely sure that they have not agreed with all the answers that I have given today—
They have not.
I have felt that, from behind me. Nevertheless, I pay tribute to any community group that cares enough about the health services that are provided in its community to embark on such a campaign. The group has raised some important issues. I know that the people in the group do not see eye to eye with NHS Tayside or me in some respects, but I hope that the on-going engagement that they have embarked on will lead to greater satisfaction over time. They have raised some important issues that will no doubt be of benefit to communities across the country, and I thank them for that.
Mary Scanlon made a good point about whether the public are confused. We have work still to do to educate the public—if I may use that phrase—about what the appropriate route to take is in different circumstances. When GP practices are closed, most of them provide a recorded message that tells patients to phone NHS 24. To a large extent, NHS 24 is the gateway to out-of-hours services. Many people criticise NHS 24 if they do not receive the desired response from the out-of-hours GP, but NHS 24 is responsible not for the provision of that service but for referring people to the right part of the service. In that respect, I think that NHS 24 does a good job.
I talked earlier about the progress that has been made by boards in out-of-hours provision, but the progress and advance that NHS 24 as an organisation has made over the past couple of years has been phenomenal. Without getting diverted into issues such as the flu pandemic, I think that NHS 24 as an organisation is performing extremely well and to a very high standard. However, we can always do more to promote awareness of the different routes into the system and we will certainly continue to look at what more needs to be done.
I do not know whether the committee has taken evidence on NHS Grampian's know who to turn to campaign, which ran over a few months early last year. That considered the best way to get across messages about who the public should turn to, and a report on the campaign came out in November. If that would be of interest to the committee, we would be happy to give further information on it.
Rhoda Grant has a question; she assures me that she has not just made it up because her original question has been asked. This question has been brewing for a while.
Yes, it has been brewing for a while.
In a previous evidence session, we heard from NHS Grampian about how it uses telemedicine to help with out-of-hours provision. When I visited the Scottish Centre for Telehealth, I saw for myself how impressive that is. However, apart from the need for health boards to adopt the technology, one barrier to telehealth in remote rural areas where it perhaps has the potential to sort out these problems is the lack of access to broadband. Unless we can get broadband out to those communities—or give health service workers access to satellite broadband, which would be more mobile as it could travel with them as they go out and about—we will not be able to untap the potential of telehealth.
That is an obvious and important point. I will not go into broadband provision in different parts of the country—the convener will be glad to know—as that is, thankfully, outwith my areas of responsibility. Nevertheless, access to broadband has an impact on our ability to maximise the use of technological solutions to some of the problems. I am more than happy to ensure, if this would be helpful, that the committee receives a written update on broadband provision and on what action is being taken to extend that.
That would be fine, thank you.
Before anyone else tries to catch my attention—I have my eyes cast down, so I do not see anyone else with a hand up—I thank the cabinet secretary and our other witnesses for their evidence.
I put on record the committee's thanks to the Kinloch Rannoch campaigners and the Public Petitions Committee. The petitions system in this Parliament is one of the few in Europe that allows people to raise issues in the Parliament that do not just get parked but feed into committee inquiries and become an important part of the inquiry itself. I wish the campaigners from Kinloch Rannoch a safe journey home. It is a long way back.
Meeting closed at 12:03.