Official Report 199KB pdf
Good morning. Welcome to the 18th meeting of the Health and Sport Committee in 2009. I remind members, witnesses and people in the public gallery to switch off their mobile phones and any other electronic equipment. No apologies have been received.
I have questions for the BMA and the Royal College of Nursing.
We believe that anyone who runs a national health service general practice contract in Scotland should have a long-term commitment to the population that they serve and that they should have day-to-day involvement in running the practice. There are issues to do with the definitions of the words "private" and "commercial". We have particular issues with commercial companies, which the bill will prevent from coming in and running NHS general practice contracts, because of our concerns about what has already happened in England.
The bill will not stop that happening. We all know that there are various ways of setting up private companies—a private franchise company could be established throughout the United Kingdom, for example. God forbid that we will have "McDoctors", but that could happen. That could be a franchise and the health service would not be prevented from contracting with it. Provided that GPs run and are in control of such companies, the health board will not be prevented from contracting with them. Does the British Medical Association really understand that part of the bill?
We do. As I said, we have lots of experience from what has happened in England, which we can tell members about. My understanding of the bill is that one of the GPs holding the contract will need to have day-to-day involvement in the practice, but that does not happen when large commercial companies take over lots of practices, manage them from a distance and the doctors are not contract holders. Contract holders will work in the practice. There is a difference between that and what Professor Pollock has issues with.
But essentially, the private element will still—
Before you proceed, does Ian McKee want to ask a supplementary question on that particular point?
Yes, if that is all right with Helen Eadie.
Certainly.
On 13 May, we took evidence from Dr Pryce of the Scottish Government's bill team, who agreed that it would be possible for a doctor or a nurse to do what is done in England. Day-to-day involvement in the health service is defined as involvement for a minimum of one day a week, so a doctor or nurse could set up in a practice for one day a week and the provisions of the bill are such that that doctor or nurse could then run other practices with which they did not have day-to-day contact—nothing is said about having to be in a practice. That is the problem. The person does not even need to be a doctor or a nurse. Administrators who work in an NHS practice could run 40 other practices. That would rule out a commercial company per se, but such an arrangement would still, in many people's eyes, be a commercial one if people were running practices without having a say in day-to-day clinical matters. That explains the situation as I understand it. Dr Pryce agreed that that was possible under the bill.
Perhaps we need to look at the wording in the bill on day-to-day involvement. I suppose that there could potentially be involvement for five days in five different practices. If, as you say, day-to-day involvement is defined as involvement one day a week and a person with that involvement could run 100 practices in Scotland, we would not necessarily support that; we would need to look at that.
A person could work a whole week in a practice and run other practices.
I agree with that summary. If that is the case, we need to look further at the bill. What you describe is the case in the majority of the GP-led health centres in England. The view of GPs in England is that that is happening. Having a contract holder who lives and works in the community and stays as the GP for patients in the long term is different from having a group of GPs or a commercial company working across primary care organisation areas and providing services on a much larger scale.
We believe that there must be a connection to the day-to-day contract and that there should not be something outside that. That is why our evidence is on our understanding of who will provide the contractual services and how that will be done.
As you are aware, amendments can be lodged either by the Government or members of the committee. You know your routes in.
Yes. I wanted to—
Sorry—Dr Marshall wants to come back on that.
There are a couple of problems with nurses holding GMS contracts. First, it is important that the holder of each GMS contract is a doctor who can provide medical leadership. The GMS contract is a United Kingdom contract. Any nurse holding a GMS contract would not have any ability to negotiate our terms and conditions and they would have no one to represent their views. Secondly, there are disciplinary regulations that relate to GPs who hold contracts. It would not be fair if the GPs who held contracts were under disciplinary regulations that did not apply to a non-GP who held a GMS contract.
In our view, the Government was brave to consider the proposal, but it said that the response was against it. According to our analysis, five parties were for it. We believe that the issues that I have raised were not properly consulted on or understood. We are not saying that there are no issues to be considered. My view of the future is that it will be not nurses against GPs, but a team of nurses, GPs and others. I am firmly committed to that. There is an example in England of an out-of-hours service whose lead clinician is a nurse who has a GP and others working with them. We sometimes think that "lead clinician" means that there is no commitment from other services.
Can I ask a question on that point, convener?
I feel that I am holding medical jackets, here, with nurses in one corner and GPs in the other. I will let Dr Marshall come in first—
My question is for Theresa Fyffe.
Please go ahead.
I am asking for some information. New section 17CA states that arrangements could be made for a partnership in which
Can you refer us to the relevant subsection, Ian?
It is new section 17CA(2)(a)(i) of the National Health Service (Scotland) Act 1978, which is inserted by section 30 of the bill.
When we met the legal team and debated that with them, they told us that they believed that it was closed down. That was the Government's response to us—that the way in which it is defined just now closes it down and there is no opportunity for nurses to hold GMS contracts. That is how the issue has been led to us. We went back to consult the Government, which is why we submitted—
We can raise the issue with the minister if there is a conflict of interpretation.
I take your point, convener, that you do not want to be holding jackets. Nevertheless, I take issue with some of the comments about who provides out-of-hours services. I realise that, under sections 2C and 17C of the National Health Service (Scotland) Act 1978, nurses and other health professionals can hold a variety of contracts, but we are talking about offering others GMS contracts. I simply point out that, at the moment, I cannot hold a pharmacy contract.
As Dr Marshall has pointed out, other contractual options are available to nurses. I also urge the committee to consider the knock-on effect of this provision on the other countries of the United Kingdom because, after all, what has been negotiated is, in effect, a four-country GMS contract.
That stirred up a wasp's nest. Helen, on you go.
I wonder whether Theresa Fyffe or the other witnesses have anything to add to the suggestion that the bill represents a complete turnaround by the Government on its approach to section 17C arrangements.
The provisions were not trailed well, which has caused concern and has perhaps led to a lack of understanding about what the wording actually means. I entirely understand what the Government is saying about the current arrangements for and issues around the GMS contract; indeed, that is why we are not asking to take things back to square one and go back to the table. If we can get an amendment lodged, we can have a better discussion of the matter and come to a better understanding of what the future might hold. I am not in any way suggesting that nurse-led services should stand alone, although I point out that certain services in Scotland—homelessness services, for example—already stand alone in that respect and will, because of their nature, always do so. All I am saying is that we should keep the discussion open. I simply do not think that it was reasonable to close down the conversation just because one party did not agree with the proposals. After all, five other parties said yes.
I will leave it at that for the moment, convener.
I call Michael Matheson, to be followed by Mary Scanlon and Rhoda Grant.
I was going to ask about smoking issues, convener. Do you want to continue with the current line of questioning?
Well, you could ask your question and see whether someone wants to answer it.
Perhaps we should stick to part 2 of the bill for the moment.
I agree. That might be helpful.
The Confederation of British Industry's submission says that, as a result of commercial companies getting involved in providing services in England, there has been a 33 per cent increase in patient lists; surgeries are open from 8 am to 8 pm; mobile units are going round rural areas; and there is
I am actually a GP in England, so I cannot answer for what happened when commercial GMS contracts were legislated for here but, if you wish me to, I can discuss the impact of commercial companies on GP services in England.
Let us have the answer to the question first.
When the Primary Medical Services (Scotland) Bill was introduced, we were reassured that the only reason that the provisions on commercial providers were included was so that they could be used as a last resort when no other arrangement could be found to provide services. That has clearly not been the case in England, where the whole thing has been turned round and the use of commercial providers has become the contractual arrangement of choice. Dr McCarron-Nash can tell you about that. We were not necessarily against the use of commercial providers because the Government of the time led us to believe, and reassured us, that it was an option of last resort, but that is not what has happened in the rest of the United Kingdom.
The point is that, five years later, we do not exactly have to close the flood gates because we still have no commercial contractors in Scotland.
I could answer that in a number of ways, but our main reservation was about amending the criteria. The unified NHS structure in Scotland is inclusive for patients, public and staff. We were concerned to ensure that, in the drive to a totally mutual NHS, we do not exclude or lose the benefits of private sector investment and innovation, which may be the only means of finding a solution to a particular problem.
I disagree with that view because of the experience in England. We thought that the provision would never be used in England but every primary care trust or primary care organisation there now has a GP-led health centre. Plurality of provision and commercial providers are being promoted as the vehicle of choice and short-term contracts are offered. In my view, there is no evidence that such contracts increase patient choice or improve patient care. They could also have a detrimental effect on local health economies, at vast expense to the taxpayer.
We are now in a position where we have two very different NHSs going in different directions: we have co-operation and collaboration in Scotland and competition and choice in England. The clear message coming out is that Scotland is going in a different direction by trying to have the public, patients and staff working in partnership. That aim could still be achieved through guidance without needing to remove, through the bill, a potential solution to future problems.
Obviously, the provision of services in deprived and rural areas is an issue of concern, but we see no evidence that commercial providers or contractors will address that problem. The experience in England, where bidding processes have been used, is that people realise that commercial companies cannot provide the services for the price that is tendered. There is actually no evidence that such contracts can resolve problems in hard-to-doctor areas.
Sorry, by the existing provisions, do you mean—just to clarify for the record—those that were introduced by that previous legislation?
Yes.
Does Mary Scanlon want to respond to that point about devastation?
There are no such commercial companies in Scotland, so the BMA can come up from England and tell us all sorts of horror stories but we have no proof whether it is right or wrong. I do not know whether any of my colleagues has been to Tower Hamlets or Canary Wharf, but the only evidence—it is unfortunate that people from the Confederation of British Industry were unable to give evidence in person—is from the CBI. The CBI submission mentions mobile units in six rural areas that received 97 per cent patient satisfaction rates; a 33 per cent increase in the size of patient lists; and surgeries that are open from 8 in the morning till 8 at night and at weekends. When I was in Kinloch Rannoch on Monday, I found that the out-of-hours service is provided by first responders. Therefore, any suggestion that all of Scotland's rural areas are covered by GP out-of-hours services is untrue.
We do not know what the future holds as far as pressures are concerned. There are many different factors involved and pressures on the NHS, not least on GPs, nurses and pharmacists. We are advising caution, as the bill reduces options and the flexibility to find a solution. The Government has itself said:
Two other members want to comment on this point.
Dean Marshall mentioned negotiating with the Government for the GMS contract. Is it not the case that, when you are a monopoly, you have a very strong and powerful hand in negotiating? Is that not the case, under the contract?
Well, the NHS is a monopoly.
But the GPs would be a monopoly provider if we barred commercial companies.
Only if we had somewhere else to go, but we do not. It is the opposite, in fact: we suffer because the NHS is a monopoly market. In my experience, it is the exact opposite when we are negotiating on behalf of GPs—we can negotiate only with the Government, and we cannot go anywhere else, so we cannot—
But the health service can negotiate only with you.
Let the witness finish. Sorry, Dr Marshall.
We cannot threaten to take away our services, so we basically have no power, and I therefore take the opposite view. Can I—[Laughter.]
Committee, please.
I want to make a couple of comments following what Mary Scanlon just said about providers down south. The evidence that she cited was the result of significant extra funding being put in by the NHS in England on top of and above the normal NHS spend. A huge amount of funding was invested. Furthermore, each PCT was told that it had to provide the service. Many trusts did not want to, but it was forced on them. If we got the same level of extra funding that the health service got down south, we could easily provide equivalent or better services.
I return to the point about enhanced services. The Government has allowed boards to provide enhanced services, which is an interesting way for boards to get close to local community planning needs and to particular issues in remote and rural areas. In its recent report, Audit Scotland cited Lanarkshire NHS Board, which has gone back to providing its own drug services in a very different way, because that is what met its needs. That is a positive way forward, and perhaps that is where there is a difference between Scotland and England. We are saying that boards should get close to their local communities and should find ways of providing services accordingly. I support that.
The evidence that we have received this morning seems to tell all of us that GPs are simply trying to protect what they have. They are private practitioners. Nobody has been able to tell me the difference between a private practitioner and a commercial one. That distinction seems to be splitting hairs. [Interruption.]
Oh! Excuse me, Rhoda. That is Richard Simpson's phone going off, so no Danish pastry for him. That is the ultimate punishment in the Health and Sport Committee.
It is too late.
He has already had one. Now all the members are rummaging and checking their phones. Sorry, Rhoda.
Not a problem.
Oh—technology! That is the difficulty with mobile phones.
GPs are not private practitioners. We are not private. We are part of the NHS pension scheme, which puts us in a different situation from commercial providers. In our view, commercial providers are those who are responsible to groups of shareholders, but that does not apply to GPs. GPs have independent practices and are independent contractors, as are pharmacists, opticians and dentists. We are independent contractors who contract solely with the NHS and we are not responsible to groups of shareholders, as commercial companies are. That is what we consider to be the difference.
Who are you responsible to, then? As private contractors, you are not responsible to the NHS, you can opt in and out of delivering services and you do not have shareholders on your back. Where is the pressure on behalf of the patient for the delivery of services? Like Mary Scanlon, I cover an area where GPs have opted out of delivering services and where it has fallen to nurses and first responders to deliver them. You will understand our frustration when you say that GPs deliver a service and do so well, but we see that that is not the case on the ground.
We are independent contractors, not private providers. Where GPs have opted out, that is because of the service that was offered and the cost. There is no evidence that commercial companies can provide the service better for less money and there is clear evidence that they cannot do so.
I will let Ms Fyffe and Mr MacKinnon answer before Rhoda Grant responds to that point.
I disagree entirely with what has been said about enhanced services. Although the Government provides boards with a minimum amount of funding for enhanced services, evidence suggests that they are increasing their spending on such services—I am not saying that they did not use enhanced services at the beginning—and are now using the model differently. The Audit Scotland report to which I referred shows examples of how boards have addressed local needs by providing enhanced services. That might be done by entering into a contract either with the GP practice or with others. I believe that the enhanced services mechanism could be utilised further in the future. The mechanism was not taken up at first, but there is evidence that its use is growing and increasing.
For primary care contractors, the ownership, investment and commitment—as well as, ultimately, the risk—rest with the contractor owner who has the contract with the NHS board to deliver NHS services. In pharmacy, we have a mixed model, in that we have independently owned individual contractors as well as large multiples, which are responsible to their shareholders. I do not think that the large multiples provide any less a service than the single independent contractors who have a contract with the NHS.
We are perhaps straying a bit, but I think that we are hearing important background information on the conflict between what might be called public delivery and commercial delivery.
To return to my original question, why cannot we just employ all GPs directly under the NHS—we could then have shift work in areas where out-of-hours cover is difficult—rather than incur the enormous costs that are currently involved in providing those GP-led services? For me, the answer to the problem is to take everyone under the NHS as direct employees.
For several reasons, that would be bad for patient care. First, it would stifle the innovation that is being sought. Secondly, it has never been offered. Thirdly, as someone who has been both a salaried GP and an independent contractor who is a partner, I always describe the issue as being a bit like the difference between driving a bus and driving a train. They are completely different jobs. Independent contractors tend to stay in a practice where they look after patients over the long term, so they have a different relationship and investment in that local health economy. As a salaried GP, I was employed to provide a certain number of hours' service to patients. Yes, professionally, the job is done to the same standard, but it is a very different type of job, in that the salaried GP is paid to go to work and can then leave. I think that many independent contractors go far above the terms of their contract and stay until the job is done. Even when funding has been withdrawn from the GMS contract over the past three years, patient satisfaction has continued to remain high and GPs have continued to deliver services, despite the decrease in funding for practices. I think that we get excellent value for money from our independent contractors.
Arguably, health professionals who are directly employed do not just leave when work still needs to be done. In all fields—certainly in hospitals—professionals do not leave the job just because they clock in and clock out. I resent the implication that only those who have a direct financial stake in delivering the service will go the extra mile and that those who do not have such a stake will not care what happens to the patient.
That is not what I said. Salaried GPs still have a professional duty of care, so of course they stay until the clinical contact is completed. However, they tend to work in a different way. Under the European working time directive, if everyone is employed, they will need to leave after 48 hours and hand on to someone else. That is a different way of looking after patients. We would run the risk of losing the relationship that independent contractors have with patients. It is a different way of working. In England, where there are an awful lot more salaried GPs, evidence suggests that salaried GPs tend to stay in post for less time and move on more quickly. That will have an effect on patient care.
Can we hear Ms Fyffe respond to that grotesque allegation of unprofessionalism by nurses and other salaried professionals? That is dreadful.
That is not what I said.
Let me say to committee members that I think that Dr McCarron-Nash was trying to make a point about the relationship that a GP contractor might have with an entire family possibly over the patient's lifetime—from whenever the woman becomes pregnant, if we consider the issue from a woman's point of view, right through to old age—because the GP contractor stays in that practice. Therefore, there is a different kind of relationship. I do not think that Dr McCarron-Nash meant to impugn the professionalism of other health care workers.
I did not mention nurses at all. I would never imply that another professional group is not professional—that is not what I said.
Please explain to me why you said that salaried people—
I did not say that. I said "salaried GPs".
You did say that. You made the point that you had a different relationship with a practice because you were independent and not salaried, and that, if you were salaried, you would clock on and clock off and be worried only about your time and not about your patient. I regret to say that that is what you said.
No, I never said that. There is a difference between someone who is employed to provide a service, which may mean seeing patients, and someone who runs a practice. A lot of what GPs do falls outside the face-to-face time with their patients. As a salaried doctor in the posts that I have had, I have worked in a clinical capacity and—yes—I have stayed until the job is done, like any professional. However, that is a very different role from running the practice, which involves a much more longitudinal relationship with my patients. That is the evidence from England, where salaried GP turnover is higher. I did not comment on other professionals.
In fairness, it would be reasonable to say that Dr Marshall and Dr McCarron-Nash did not comment on nurses. The debate about salaried versus independent is interesting, but I am not going to go there. Dr Marshall and Dr McCarron-Nash feel very strongly about that issue, given their particular role. However, I will say that someone's commitment to a service is not necessarily different depending on whether they are salaried or independent.
I do not think that the committee thinks that. I think that we may have gone down the wrong route here. I accept that Dr McCarron-Nash did not mean to impugn other professionals in talking about the slightly different relationships involved in the long-term treatment of a patient or family and so on. I see that Miss Fyffe is nodding to that. We will move the discussion on from that issue.
My basic concern is monopolies, which are not a good thing because we do not get competition with them. There is evidence that we do not get competition in the sense of people being prepared to look very carefully at what they do. The problem with general practice in Scotland, which is pretty good on the whole, is that there are areas where it is not good and there is no significant mechanism to improve it. I will give two examples, one of which is about the management of care homes and the patients there. The recent evidence about the use of drugs in care homes is not new information, as that practice has been going on for years. The primary care aspect of the management of care homes has been neglected for many years. Individual patients register with individual GPs who have no expertise in dealing with such patients, there is no partnership with pharmacists, which is very important in terms of the drug issue, and there is no integrated care.
I have lost the will to ask members of the committee whether that is the case; I just let them speak.
There was an excellent article in the employment section of the British Medical Journal about the setting up of a quasi-commercial operation in London, which has taken over a number of practices that were regularly staffed by locums because no GPs would take them over. If a similar situation should arise in Scotland, the bill will mean that a Scottish health board would not be able to ask such a commercial company to provide a service to patients. What guarantee can you give us that that will not happen in Scotland? Surely a provision of the sort that you seem to favour, whereby the use of a commercial company should be a last resort, would be preferable to ruling it out altogether.
You have raised a whole load of issues, which I am happy to deal with, but I must provide a bit of historical perspective. The contract that was brought in was negotiated by the BMA and the Government at the time. The Government's big thing was to remove the preferred-provider status of GPs so that we would not be the only people who could provide services. The Government wanted to have a market and it got it, but very few other people have ever entered that market because of the cost of providing those services.
A number of the companies that have been set up in England have been set up by general practitioners. People such as Richard Smith are heavily involved in that.
He is not a GP.
No, he is not. He is a former editor of the BMJ.
He is an employee of a large, worldwide company. He is not a partner.
No, but he is heavily involved.
You asked whether we would be looking at where the system worked well as well as where it did not work well. We have to remember that the commercial firms that have won the tenders have had an awful lot of pump-primed money. Each polyclinic or GP-led health centre has had an extra £1 million per PCT spent. The playing field is certainly nowhere near level. In three or four years' time, when the money has to come out of the PCT, the issue will be what effect that has on local services. GPs who already have contracts with the PCTs were not offered the chance to provide extra services, so we are not comparing like with like.
It is always interesting that when we consider the principles of a bill we expose slightly different issues from those that we started asking about. I do not think that any of the members or witnesses is unclear about what the Government is trying to do in placing serious restrictions on the development of private contractors in the NHS in Scotland. However, the more one looks at the wording of the sections, the more questions one has about whether they will deliver what the Government intends.
I will answer the first couple of points. You may have heard of the BMA's support your surgery campaign, in which I was involved. The public in England were not asked about the change in policy towards a more commercial system: 1.3 million people have said that they are not happy with the route taken by the Department of Health in England. I agree that everything that happens in England seems to arrive north of the border at some point, and there is a concern that if we do not close the loophole, we will not future-proof general practice in Scotland.
Under the bill, there will still be a variety of contractual options in Scotland. We will have GMS, which is an independent contractor model. We will also have section 17C, under which boards can set up practices. That provision has not been used very much recently, for a variety of reasons—for example, the money that was previously put aside for that purpose no longer exists. As Dr Simpson said, section 17C can also be used to set up other services, such as care homes. The contractual options are available, and we are not talking about removing them, but they are not being used, because there is no longer any identified funding.
To return to the point about developments arriving north of the border, the most recent health service changes show that that is not happening in the way that we thought it did for a number of years: we thought that if something happened in the south, it came to the north. I am part of a UK organisation, so I can see the whole health care picture. We consider various things and say, "That does not fit in Scotland." We have learned from other countries as well as England, so perhaps too much is made of that concern.
One of the difficulties—or rather, one of the challenges—in discussing the principles of the bill at stage 1 is that we need to look forward. Dr Marshall makes the point that, when negotiations take place that involve devolved Administrations but a single outcome is sought, a compromise is inevitably involved, but it is not just a compromise between the principle and the negotiator; we also have the inter-devolved-Administrations issue. Some of the comments that have been made therefore seem a little odd.
We can do something radically different. We did that with the pharmacy contract in Scotland: we stood it on its head and moved the focus away from the importance of prescriptions towards improving clinical outcomes for patients with new pharmaceutical care services. We now have a radically different contract from England and Wales, with patient registration and capitation. In fact, it is unique in the world. We can engage with the mutual NHS and produce something different. We are still negotiating that contract at the moment.
Next time I come to the committee, I will have to prepare to discuss any part of the contract, because a lot of what we have discussed is not in the bill. However, I am happy to discuss it, and it is great to have the opportunity to do so.
I let the discussion run because it is useful background on the issue of public versus private. It is as simple as that.
On the UK contract and the Scottish contract, as Theresa Fyffe said, we have the benefit of having a second bite at the cherry when matters come back to Scotland. From day one, there have been differences between the contract in Scotland and the contract in the rest of the UK, and each of the devolved nations has bits that are different from the UK contract, even involving the fundamentals. For example, funding is allocated in practices in Scotland according to a Scottish allocation formula and not a UK one, so the position is different from that point of view, and the directed enhanced services in Scotland are different from those in England.
I accept Dr Marshall's point. He has to understand that we have broadened out the discussion because we are discussing the general principles of the bill. The next difficulty will come when we discuss the wording of the bill line by line, but first we have to be clear about whether the principles that the Government is enunciating are met by what is proposed, so it is helpful to consider the contextual framework.
Helen, is your question a short one? I want to move on.
I seek clarification of Dr McCarron-Nash's answer to Dr Simpson. She said that £1 million was injected into the primary care trusts, but that was a one-off pump-priming exercise for infrastructure, which will not necessarily be reflected or required further down the line.
That is correct, there was pump-priming, so we are looking at satisfaction rates and access that are not comparable with existing investment in GMS. Local surgeries have not been offered the chance to extend their hours or provide other services. That is our argument.
That is on the record. I recall the point being made. It was a one-off. Helen Eadie's question was, "Will this not be repeated?"
However, Dr McCarron-Nash inferred that the funding might be required further down the line as well.
Yes. I inferred that there could be a knock-on effect on local health economies in the future. Obviously, if investment is made in something, there will be less money for other things. Difficult choices might have to be made.
I find it difficult to reconcile the fact that the funding was a one-off and the fact that it will be needed further down the line. That is all.
I was satisfied with the explanation that we got the first time; nevertheless, that is on the record.
I will please Dr Marshall by returning to the bill, but my question is for Theresa Fyffe and Alex MacKinnon. Section 30, which is in part 2, on primary medical services, will insert proposed new section 17CA into the 1978 act. The proposed new section concerns "Primary medical services: persons with whom agreements can be made" and says:
You are absolutely right that, at the moment, under section 17C of the 1978 act, health boards can contract with health care professionals on the list that you read out to provide primary medical services. The Government proposed equality of eligibility criteria between primary medical services and the GMS contract but stepped back from that. You are right that eligibility equality is possible in one aspect of primary medical services, but we say that it should be opened up across the board. The Government stepped back from proposing equality of eligibility criteria because there was a view that it was a step too far at this stage. We say that there should be consultation and debate about the very thing that you are exploring: what would the difference be between providing primary medical services under section 17C or the GMS contract? What difference would that make? We have not debated that question. My point is that we never got into that debate and understood what such a proposal would look like.
That was a very clear explanation of all the different contractual arrangements that even I understood.
We were unclear about the intention of that bit of proposed new section 17CA. It needs a wee bit further scrutiny.
It seems quite clear.
Michael Matheson wishes to ask a question about part 1 of the bill, which the witnesses may or may not wish to answer.
It is only right that the witnesses have the opportunity to comment on part 1, which is another significant part of the bill. I suspect that they will largely agree with one another on what the Government is trying to do on the control of tobacco advertising.
As practitioners in primary care, we are all committed to getting people off smoking through smoking cessation schemes and so on. A ban on smoking in public places was introduced by the Smoking, Health and Social Care (Scotland) Act 2005. It is logical to take that a bit further now by going down the route of prohibition of the display of tobacco products and making tobacco products less easy for youngsters to obtain. The statistics speak for themselves with regard to the number of 15-year-olds who smoke, which we think is unacceptable. However, there must also be more education to link in with the prohibition that is being planned.
We are members of the Scottish coalition on tobacco and we absolutely support the action that is proposed. The facts and figures show that an increasing number of 15-year-olds and other children are smoking, and we think that the proposals send a clear message that that needs to be stopped. That is a good health message.
Both of you have referred to the figures on young people smoking. However, the tobacco companies led us to believe that the banning of tobacco displays in other countries did not appear to have any impact on reducing the number of young people who smoked.
The solution involves a raft of measures. If you introduce a prohibition on the display of tobacco products without also introducing all the other necessary measures, such as smoking cessation clinics, of course it will not have the desired effect. I would be surprised if you could get evidence that any one measure had had an impact. Rather, what will have an impact is the raft of measures, as that will send a clear message to the Scottish population that the problem must be addressed. A cultural change is needed. If you are saying that it is okay to display cigarettes in the way that they currently are, you will not get across a message that will bring about a cultural change.
You will find that, in countries that have introduced an apparent total ban on the display of tobacco products, the tobacco companies have found ways of doing more direct advertising.
Such as?
Sending out direct mailshots and so on.
Texting.
If the tobacco retailers do not think that banning tobacco displays has any effect, why are they against banning them, and why are they spending such a huge amount of money on advertising?
You keep using the word "advertising" in a broad way. Tobacco advertising has been banned, of course. When you talk about cigarettes being advertised to children, what are you talking about, in practical terms?
Having the brands in front of children in shops is a form of advertising, as far as I am concerned. Perhaps my definition is different from that of others. I am talking about point-of-sale advertising, which normalises cigarettes. I know that people have said, "What about alcohol?" However, that is a different case, because we believe that there is probably a safe level of alcohol intake, but there is not a safe level of tobacco use. That is why we support the Government's proposals.
I hope that the committee does not mind, but I would like to draw this evidence session to a close, as we have rather a lot to get through today.