Health and Community Care Committee, 03 Nov 1999

Meeting date: Wednesday, November 3, 1999

Official Report 208KB pdf

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Arbuthnott Report

I welcome our visitors from the BMA. Good morning, gentlemen. Please introduce yourselves to the committee and, if you want to, give a short statement to precis some of the points in your written submission. We will then ask you questions about your submission and about the report in general.

Thank you. We are delighted to have this opportunity to give evidence to the committee and to answer members' questions. We are keen to contribute constructively to the debate on a range of issues about health and health care provision in Scotland. We are pleased that our invitation here today signals a much more open form of parliamentary democracy.

The British Medical Association in Scotland represents about 13,000 members from all branches of the profession—medical students, junior doctors, consultants and general practitioners. That representation is channelled through the democratically elected Scottish council, of which I am privileged to be chairman.

With me are Mr Rab Hide, a consultant neurosurgeon at the Southern general hospital in Glasgow and chairman of the consultants and specialist services committee of the BMA, and Dr Kenneth Harden, chairman of the Scottish general practitioners committee of the BMA and a GP in Glasgow. They will help to answer any questions.

I will start with a few general remarks about the report "Fair Shares For All". Last year, the BMA's policy was encapsulated in two short statements. We said that the Government should continue to confront the most potent cause of poor health, which is poverty, and that we recognised that health was determined not only by health services, but by political, social, environmental and personal factors. We also called for the development of and wider use of health impact assessments in all areas of national and local public policy.

We are very supportive of the aims of the Arbuthnott report to address health inequalities. We accept, however, that the Arbuthnott report covers only the division of the health service cake, which is only part of the answer in reducing health inequalities.

In the past century, the principal improvements in health have come not from people like us—nurses and doctors—but through better sanitation and water supplies. In the next century, we hope, much will be achieved through better education, diet, housing, transport and the reduction of poverty.

The BMA is concerned that Arbuthnott has not addressed the overall size of the cake. We would argue that a significant uplift in resourcing is needed to achieve the goal of health equality for all.

We broadly welcome the report and the principles that underlie it. We recognise that, for acute services, the report represents only a small shift from the Scottish health authorities revenue equalisation formula, but that such fine tuning is important. Based on the evidence available to it, we acknowledge that the Arbuthnott review has produced a very professional report. We particularly liked the recommendation that evaluation and refinement should continue. We also agree that some areas, which are listed in the report, require additional research.

We want the Health and Community Care Committee to consider the issue of unmet need, which is talked about a lot in the report, and how unmet needs vary across the country.

Met wants can also vary across the country and must be provided for. Met wants are the things that the health service and taxpayers pay for but that may not result in positive health outcomes. Met wants could include, therefore, explaining to a 63-year-old fit male who comes into a surgery that he does not require a flu jag as he is not at risk—that takes time and resources. They may also include dealing with a drug addict who comes in for an increase in his drug prescription. That takes time, investment and resources, but it does not result in a positive health improvement. Met wants may also affect hospital accident and emergency departments. For example, a chap may return with a sore back because he wants an X-ray and a second opinion. Again, that is not improving health, but it is something that we on the front line, and especially in general practice, have to deliver. We want that area to be explored.

The proposal to bring about changes to hospital and community funding though differential growth is welcome. However, the suggested time scale of six years is dependent on the size of those general and specific uplifts. A tension exists between the need for change and the need for minimal disruption. A low uplift in a potentially losing board would make it difficult for that board to fund new, essential developments. If the committee wants, we can talk about those developments.

We are disappointed that the review did not propose that the additional resource provision should be targeted at the causes of health inequalities that have given rise to this redistribution exercise. We are keen that only effective treatments with positive and proven health outcomes should be used. Members may have seen The Scotsman on Friday, in which our colleague GPs in Easterhouse expressed their worries about the allocation of public moneys to baby massage, reflexology and acupuncture, which do not address the real problems of health inequalities in Easterhouse. Our members were concerned about that.

Finally—and I know that this is an area of particular interest for the committee—we have major concerns about the suggested indicative allocations for non-cash-limited general medical services. We believe that further work and discussion is needed in those areas before implementation.

We have three principal concerns. The first is the lack of a reality check, as we call it, on the proposed formula for the non-cash-limited GMS. The idea that there can be a reduction or a zero growth in GMS resource at a time when we are emphasising the shift of resources from secondary care to primary care is, in our view, untenable. Secondly, we have concerns about the way in which remoteness and rurality have been measured. Finally, we have concerns about the continuous morbidity recording in the report. Dr Kenneth Harden, who is the chairman of the Scottish general practitioners committee, is happy to give a short presentation on those three areas, if the committee wishes.

Overall, the BMA is saying that the report represents a good start, but that more work needs to be done. We welcome the opportunity to be part of that additional work. Thank you, convener, for allowing us time.

We certainly intended to question you on two of those last three things that you mentioned, so it would be useful to hear from Dr Harden first.

As John Garner was saying, Scottish GPs welcome the development for the first time of an equitable distribution model. However, it is essential to recognise the deficiencies of the model that has been proposed. Several loading factors are used for GP payments. One of the main ones is continuous morbidity recording. That system is based on a number of volunteer practices. Inevitably, a system that bases itself on volunteers is atypical. That is illustrated by the fact that, for example, the system involves only 6 per cent of the practices but covers about 11 per cent of the population of Scotland. The practices are substantially bigger than average. Only 3 per cent qualify for deprivation payments as opposed to 11 per cent of practices in the country as a whole. The only aspect of work load recorded in the system is the number of consultations, whereas, for a true record of work load in general practice, it is clearly important also to record the duration of the consultations and other aspects such as telephone consultations and nurse consultations.

We were concerned that the method of validating sparsity in general practice used the current payment structure, which seems to us to be a rather circular logic. Some methods of measuring actual additional costs seem to be much more appropriate than using the existing payments system. Some of the results produced are counter-intuitive—for example, the suggested major reduction in the funding of GMS in the Borders.

We note with regret that the Arbuthnott committee does not seem to have taken dispensing payments into account in its calculations. That has a significant effect on payments to GPs in rural areas who do dispensing as well as general medical services.

The report did not consider the problem of inducement practices. Where a practice is considered essential, the current arrangements ensure the payment of more than 80 per cent of average intended net remuneration to inducement GPs. It is unlikely to be possible to ensure the provision of adequate GMS in those areas without the inducement scheme or a comparable expenditure. There seems to be a case for top-slicing the payment in terms of the irreducible minimum of such areas.

The move to a rational, equitable basis for allocation of GMS is welcomed, but much work is needed to establish a more robust system to measure both need and demand in primary care. Considerable thought and planning is required to establish an effective and safe method of implementing necessary change.

Thank you for that full and useful statement.

I have quite a few questions. As a member for the Highlands and Islands, I was delighted by the report, because we seemed to be one of the winners. However, my delight was short lived because you say in your submission that the Highlands will lose 20 to 30 GPs. You also say that Orkney will lose 40 per cent of its GPs, that Shetland will lose 33 per cent of its GPs and that the Borders will lose half its GPs. We are looking towards primary care for health promotion, monitoring heart disease and meeting the Government's targets, but if the money is not going to primary care, where is it going?

The second point that you raised was the transfer of resources—that issue was also raised by Graham Watt. We have a concern about the volume of the transfer of resources from secondary to primary care.

How can we be sure that the resources will address poverty, inequality and deprivation? If the Highlands are going to benefit, how can we be sure that the crucial problems of poverty and deprivation will be met by those resources? It looks as though the money is going into a big pot—beyond that, it is neither monitored nor checked.

Those are cogent points, which need to be addressed. We need a robust method of measuring the factors such as deprivation. The present system of measuring work load—through CMR—does not adequately do that because of the atypical nature of the practices. As you rightly point out, the redistribution of resources has major implications. In the Borders, for example, there is a suggested reduction of 27 per cent and, in Shetland, there will be 39 per cent less.

If I might correct you, the figures for the Borders seem, in your submission, to suggest a reduction in the number of GPs from 77 to 38.5—a 50 per cent reduction.

Let me explain that point. The reduction in resources is 27 per cent, but the implication of the reduction in resources is much greater in terms of the numbers of GPs. Under the current system, there are certain basic payments, such as capitation fees, which continue. If the only reduction that can be made is in the number of GPs, the reduction costs have got to be in basic practice allowances. That will have a much greater effect on the number of GPs than the simple reduction in resources would indicate. That is why there is that difference in the number of GPs.

Are you saying that if the recommendations are implemented, inequality of access, poverty and deprivation might increase? We will not have the GPs to carry out the services. If what you say is correct, the Arbuthnott committee will do the opposite of what it set out to do.

The proposed formula poses a real danger and we welcome the fact that the Arbuthnott committee has suggested that the GP formula is purely indicative and out for consultation. The committee recognises, following our discussions with it, that there are major disadvantages, or defects, in the proposed system, which must be considered. As you rightly point out, if the proposed changes were made—for example, in the Borders, in Shetland or in Orkney—they would have major detrimental effects on the provision of GP services in those areas.

I have a supplementary question. Are you saying to us that the GMS should be excluded from this process, because the data are inadequate? One of the questions at the beginning of your submission is this:

"Why has GMS been included in this at this point in time?"

However, this morning you are saying that, although you welcome the fact that someone is attempting to do something about the situation, the changes in GMS are so significant in Grampian, Borders, Lothian, Orkney and Shetland—as shown in table 14.5 in "Fair Shares For All"—that they would have a totally destabilising effect. Am I correct in thinking that?

You are absolutely right, Dr Simpson. If this formula were applied now, it would have a major destabilising effect on services in those areas.

That is worrying. I would like to continue the line of questioning that I started last week. Your submission states:

"We have a general concern that implementation of the report's recommendations will lead to a lowering of standards in those areas which are ‘closing'."

I refer again to Lothian and the Highlands. Many specialist services are offered in Lothian, and the health board said that it would have to address that. The Highlands stand to lose not only GPs, but some of the specialist services that cannot be offered in remote rural areas. Do you share that serious concern?

Perhaps I can answer that. I understand what you say about the specific problems in rural areas. The possible knock-on effect in specialist services may affect all patients. Many of the services in question are tertiary or major secondary services.

There are two problems, which are perhaps not detailed in the Arbuthnott report, but which certainly impinge on that report's conclusions. In this country, we seem to have had difficulty in producing true costs—the true costs of procedures, of acute sector care and of general practice. We have tried, but seem to have failed, to develop a robust system of coping with what we call cross-boundary flow—of ensuring that money follows patients. Many words have been spoken and many theories put in place, but at the grass roots—at the coal face, rather—it sometimes seems that that is not happening. That was a distorting factor in the care formula.

It is all very well for us to be critical. However, can the BMA provide a workable definition of equity of access to GPs, irrespective of the density or profile of the population?

I will turn my microphone off to answer that question if I may, convener.

No. We get into trouble if we do that kind of thing.

That is a matter that concerns the English language as much as the Arbuthnott report, but I would be delighted to hear my colleagues' responses. I have my own thoughts about equity and equality of access.

We are talking about the implementation of a new system of distribution. Looking back to the implementation of the SHARE formula, can you provide any evidence that that formula had any effect on the quality of care in different health board areas?

One of the difficulties that I have perceived in the reports and some of the transcripts is the interpretation of the data that are available. I have been a consultant in the Scottish health service for 30 years and I have little doubt that, following the SHARE report, there has been a considerable improvement in basic medical care facilities in many health boards that were relatively deprived before. Argyll and Clyde Health Board and Ayrshire Health Board, for instance, were able to develop core specialist services. The difficulty was that the report affected some of the major centres that supply services beyond the core ones, as we have heard from Lothian Health and Greater Glasgow Health Board.

I would like to consider further the numbers of GPs, as that was the headline story on the radio this morning and I suspect that it will be in the headlines after today's committee. Your submission contains other important points, but we need to clarify what we are talking about.

I understand that the cash-limited GMS will kick in more slowly than the main parts of the Arbuthnott recommendations; as the GMS that is not cash limited is just indicative, it could be argued that it will not kick in at all. Perhaps it is misleading to cite those GP figures, because to do so implies that the changes will be made immediately.

The general model for Arbuthnott is that changes will kick in according to the growth rates in the health budgets—I agree with Dr Garner that that is right. If that is true for the GMS figures as well, what is being suggested is a levelling up and there should be no cuts in the GMS budgets. If that is what Arbuthnott intended, would you be happy with that?

The professor of general practice at Glasgow—although Glasgow gains from the change in formula—suggested to us that not enough account has been taken of factors such as deprivation and inequality. Do you accept that adjustments will have to be made to GMS? If the adjustments involved a levelling up, would you be happy to accept them?

I accept what you say: the figures are indicative. We are questioning whether they are correct. We want to know whether there has been a sufficiently full analysis of GP work load in tackling health problems. We are not convinced that the figures provide the right baseline.

I accept what you are saying. I am aware that there are differences of opinion on this matter, but the professor of general practice at Glasgow said that if length of consultation and co-morbidity were taken into account, the adjustment might be large rather than small. That is open to question, obviously, and your point is that you want more work to be done on the figures.

Absolutely.

That is an important issue. We are suggesting not that there is no need for a formula, but that the formula is not based on evidence. It is based on an inappropriate sample, using inappropriate techniques.

You said that we should not worry too much about the figures, as they are only indicative. However, many of us have seen indicative models rapidly become real models. If we do not register our objections to the basic principle and start to gather robust data, there is a major danger that inappropriate models will be imposed.

Clearly, the Scottish Medical Practice Committee is important in relation to the GMS that is not cash limited. To what extent are factors such as deprivation and inequality taken account of in the allocation of money?

As a member of the committee you mention, I am well placed to answer that question. At present, sparsity and rurality are taken account of by a formula that allows notional patients. Those formulae have not been used in the Arbuthnott report.

The other aspect is that the Scottish Medical Practice Committee has limited powers to influence distribution. It ensures that areas are not over-doctored, but it has little power to deal with the more important issue of areas that are under-doctored.

Does the SMPC take inequalities into account?

It takes deprivation into account. It uses the existing deprivation payments to recognise deprivation and it uses the rural practice payments to recognise sparsity.

I am aware that you have already told us what changes you think would be brought about, but do you intend to conduct a study of the formulae and apply them to a set of assumptions so that they can be modelled?

Are the concerns that you expressed about the shifts related to the way development costs are considered, in terms of health costs and health inflation?

We have addressed the problems that your first point referred to with the Arbuthnott committee. It is considering the weaknesses in the current information. There is a need for some forum that can do more work in the area. I do not know whether that should be the Arbuthnott committee or its successor or whether the responsibility lies with the Scottish Executive.

Your question on development costs is important. The suggestion that you and Mr Chisholm made is that changes can be absorbed simply by standing still. That is a fallacy because applications for increases do not keep up with health inflation, although they might keep up with general inflation. If an area is not receiving significant additional resources, particularly for general medical services, it will have to cut down on other areas. We need development costs in primary care to extend the range of services to provide an extended range of intermediate services. There is no reference in the report to the development of intermediate care to provide services in a site that is more convenient to the patient and at a level that is more cost-effective.

Dr Simpson made a point about the size of the development money. If a board has only a health-based rate of inflation, it will have no ability to resource essential new developments that come automatically. An example of that would be the introduction of the statins. They will be available throughout Scotland and will cause a significant increase in the health budget.

The losing boards need an ability to stand still as well as some money for essential new developments.

In terms of CMR, you said that volunteer practices were atypical, Dr Harden. How were those volunteer practices identified? Were they identified through the British Medical Association?

Not at all. They were written to and asked whether they were willing to take part in a voluntary project of data collection. A small payment was made for staff, but no payment was made for the GP.

The result was that in areas where practices were extremely hard pressed—such as very deprived areas—there was a great unwillingness to participate. The danger was that spending more time on data collection would be to the detriment of patient care. At that time, the purpose of the exercise was not made clear; at no point was it made clear that its aim was a logical redistribution of resources. If that had happened, I suspect that many practices would have been more willing to participate and would have done so more reliably.

However, the request did go out to all GP practices?

Only to those with particular computer systems.

I see.

That is the majority.

Something you said puzzled me. You started off by saying that certain things were recognised with payments, but that because no payments were made to GPs some were reluctant to participate. Is that correct?

Yes.

You went on to say that one of the reasons that many doctors, particularly in hard-pressed practices, did not participate, was overstretching—people felt that it would be detrimental to patient care. I cannot understand your argument that, if GPs had been paid, they would have participated and patient care would not have been prejudiced, but that patient care would have been prejudiced if they had participated without being paid. Am I missing something here?

This is a resource issue. It is not about the GP wanting more money for himself, but about a greater input of general medical services being required. Let us take the example of a GP who has assumed the role of chairman of one of the local health care co-operatives. It is not expected that he will be able to do that job in addition to providing existing general medical services. Quite rightly, it has been recognised that he will need locum payments to cover his absence when he is away on local health care co-operative business. Similarly, if any sort of additional work load is created, there is the option of buying in extra locum help.

So any additional payments would have been used to purchase additional services, not to compensate GPs personally, and their reluctance to participate was the result of their inability to purchase extra services?

That is correct. If I were a doctor in Easterhouse who was stressed because of the drugs problems there, and someone asked me to collect some data—without saying what those data were for—I would be inclined to give my attention to the drug addicts and the problems of the area, rather than to data capture.

One of the most frustrating things about this report is that a vast amount of work has been done on shifting money around—I call it spreading the margarine more fairly—but no extra money has been provided. I would like to refer you to a few points in your report.

First, you say:

"the Review Committee obviously takes a different view of the reliability of hospital data to doctors, who generally have little confidence in such data."

Could you expand a little on that?

Secondly, do you consider that this formula gives local boards and local doctors any protection against private finance initiative developers influencing the number of staff employed in hospitals, as has already happened?

My third point relates to the era of more expensive drugs that we may be entering. Multiple sclerosis patients have asked me about beta interferon prescribing in particular. Do you have any feedback on that?

Dorothy, you are straying.

It is what the public wants to know, Margaret.

I gave you a certain amount of leeway when you pinched Margaret Jamieson's question, but you are now going into all sorts of other areas.

If she had been here on time—

Dorothy's key question was about the quality and availability of the data. In their oral and written submissions, several people have told us that they do not have a problem with the theory of this report, but with the fact that, if that theory is based on inadequate data or data that are rooted more in the acute services than in the primary and community services, it is very difficult to get a picture of future need, rather than a snapshot of the situation in the past. Could you comment on the reliability of the data, identifying any key gaps? We have already picked up on some of those.

Excuse me, convener, are you cutting me out on the PFI question, or are you saying that that matter has already been covered? I did not hear it being covered.

I do not think that that is the point of this morning's questioning, which is about the Arbuthnott report and the quality of the data that were available to the committee.

That is all very well, but PFI will affect hospitals in a major way. With respect, I would like to hear the BMA's view on that and on what protection the formula may offer.

Dorothy, you might like to hear the BMA's view on many things—I am interested to hear what the association has to say on any number of issues. No doubt, at some point in the future you will hear the BMA's view on PFI. Unfortunately, you will not hear it right now. What we are going to hear now is its view on the quality of the data that were available to Sir John and his team when they put together their report.

We are definitely in the new democracy, then. Thank you.

That is just offensive. After coming to the meeting late, Dorothy is attempting to take it in a totally different direction.

It is a direction that the public would like us to take.

Has Dorothy seen the front page of today's Daily Record?

I have not read the Daily Record yet.

Colleagues, I think that I have made my position on Dorothy's question clear. Is my decision backed by the majority of members of this committee? Is everyone happy that the questioning is going in the right direction?

Yes.

Thank you, you may continue, gentlemen.

I will ask Mr Hide to respond to the first part of the question, about data verification and the quality of the data.

If anybody around this table is not completely aware of the BMA's position—[Laughter.]

One of the difficulties with data is that when they support people's own point of view, they think that they are great, and that when the data do not they think that they are flawed. That is always a problem. Data in the acute sector fall into three main areas: activity data, which are generated largely by trusts; work load data, which are collected by a combination of professionals and managers; and clinical data.

Clinical data are flawed, in the sense that the coding exercise that takes place for individual patients is very often erroneous. However, the robustness of those data is acceptable overall, in a comparative sense. Those are the data that are produced by the information and statistics division. Because the data are wrong in detail, it would be difficult to use them to fine-tune things—to get accuracy, one would have to go back to the hospital in question and work through the basic records.

Work load data are fairly well collected in the acute sector. It was necessary for trusts to develop quite robust systems during the purchaser-provider divide because their money depended on their getting clear and accurate evidence of activity. Those systems took a while to develop. The odd thing is that trusts have them in place now they no longer need them, whereas in the early stages of the purchaser-provider system they did not have the data.

The problem with some of the activity data is that, generally, they do not quite fit with reality. For that reason, we suspect that inaccuracies are creeping in. As yet we have very little knowledge about, for example, out-patient data. Some of those data are probably quite significantly flawed. However, we can use postcodes to work out from which areas patients attending the out-patient clinics of hospitals are being referred.

To sum up: the clinical data are flawed, but useful for comparison; the work load data are quite robust; and some of the activity data are erroneous. The difficulty is that unless someone else gathers the same data so that we can make comparisons, it is difficult to offer informed criticism. In some areas we have done that. I chaired part of the acute services review. When looking at neurosurgical activity, we went back to the operating books to see what operations had been done and compared that with the ISD data. Although the data were wrong in places, they were equally wrong for all, so they were still useful.

A levelling down.

Grampian Health Board is one of the major losers from GMS. Do you agree with its statement, that

"For non cash limited GMS the linkage to consultation rates has also been queried, as this process fails to recognise the complex national payment system in place where circa 60% of spend on GP services is driven by patient head count and not consultation rates."?

That is a valid point and illustrates the difficulty of the existing collection system, which everyone accepts is not tremendously reliable. All it does is count the number of consultations. It does not count telephone consultations, which are an increasing proportion of consultations in affluent areas, or nurse consultations, or the duration of any consultation.

Mr Hide is right about the accuracy of hospital data. Millions are spent on it. The collection of data from general practices is much poorer. Figures are based on only 6 per cent of practices, which volunteer to collect data and are not usually aware of the purposes for which they will be used. There must, therefore, be considerable doubts about the validity of the data, and the point that Grampian makes is fair.

Grampian may have made that point because it has been an innovator in primary care and may be ahead of other areas in moving to nurse consultations. You could argue that it has lost out because we are not counting nurse consultations. I do not know the answer, but that is a possible explanation for why it appears to be a bigger loser.

That point was raised in other submissions. Lothian Health said that the report does not reward innovation.

Hugh Henry made a point about payment. If the 6 per cent you mentioned is inadequate, what would you deem adequate? Have you estimated the cost if that proportion is changed? Presumably it would have serious implications for any future review.

That is a complex question. In broad terms, at least 10 per cent of practices should be included for validity and it should be a representative sample rather than a self-selected group—which may well be practices with more time on their hands and more interest in data collection.

We would have to work out the cost implications.

Would you be able to do that?

Certainly, with the help of our experts, we can estimate the costs.

Would it be acceptable in written form?

Could you confirm that the practices that participate are those with more time?

I did not understand that either.

It would seem more likely.

You did not say it was more likely, you said it was those with time on their hands.

It is hard to explain otherwise the fact that a significantly lower percentage of practices in highly deprived areas collect data. As a practising GP, if I were hard-pressed I would be more likely to give time to patient care than to number collecting.

I think all GPs would argue that they are hard-pressed. We are talking about general practices that have the resources to restructure the working environment to allow them to co-operate in data collection. I would not want the committee to be given the impression that there are GPs sitting around waiting to collect figures.

I do not think that we would have inferred that from your comments.

I will not mention CMR in relation to hospital activity again, as I have one of the participating practices. [Laughter.]

He has time on his hands

In that case, can we review our position?

My golf handicap does not bear that suggestion out—it has gone up by six.

The answer that Dr Garner gave is correct. We should be able to restructure and to pass on some of the work to nurses and clerical staff. That is a very complex issue relating to inner-city practices and there is much material available on that, which the BMA will know about.

I want to ask a general question about the hospital data. I accept Mr Hide's point about the out-patient data being inadequate. Does he agree that, regarding much of the activity data that were collected, there was almost a perverse incentive to generate activity? Patients were being kept in the secondary care sector inappropriately—and that is still going on. Does Mr Hide have any concerns about the way in which the Arbuthnott report approaches this issue? I ask that in relation to the perverse incentives that it offers by being based on historical data. Innovation is not rewarded, but activity is—even if that activity has been inappropriate.

One always has some reservations about looking backwards and building a base on what has gone before without considering what will happen in the future.

It is always possible that doctors will be said to be gaming with the system. Figures can be manipulated honestly and patients can be kept in for longer, but that was not done by clinicians. It was done by managers because—for obvious reasons—they had a major vested interest in ensuring that they maximised activity. That has not been the case since the end of the division between purchaser and provider and since the move towards more co-operative developments in health care.

It is in the interests of managers and doctors to be honest and accurate. That is the way ahead that will generate the changes that most of us wish to see in the health service. Your second point was about what, Dr Simpson?

Does the report reinforce perverse incentives?

In the sense that it reinforces the conservative elements in all the health care professions, I would tend to agree that it does.

One must look at the future as well because patient expectations are extremely difficult to define. All the doctors round this table are well aware of the effects of the internet, of increased media interest in health care and of health care technologies. All doctors are subject to increased demands from patients to provide standards of care which, historically, there was neither the funding nor the organisation to provide.

I would like to say something in relation to Dr Simpson's point, which also relates to the transfer of resources from secondary care to primary care. Primary care has developed considerably, but Dr Simpson's point is that if we were to stick with historical models, resources would stay in the acute sector and would not be transferred to the community and other innovative health care.

We need a formula that will not remain the same for 20 years, but will follow trends in innovation that might occur in the delivery of health care.

It was said earlier that this report is about how we carve up the health service cake, and that that is only a part of the wider picture for health care. Kay has a question that leads on from that.

I have a particular interest in community care and resource transfer from health boards to local authorities. I notice that your contribution mentions the difficulties that are caused by variations in funding from one local authority to another. There appears to be evidence that not every local authority in Scotland is spending the indicative amount for community care. How could the variations in funding between local authorities affect levels of demand on the health service?

That is a good point. Arbuthnott does not take existing provision into account in assessing social services resources, but it is a major indication for hospital and general practice services. For example, an inadequate number of nursing home beds creates a backlog of patients who are waiting to be discharged from hospital because there are no nursing home places to move them to. They are the so-called blocked beds; their number varies according to the availability of nursing home beds.

In the community, the provision of support services such as home helps has major implications for patients' ability to receive care in their own homes instead of in a hospital bed. There are many areas in which social service facility provision is an important determinant of health needs and health provision requirements.

It is not usually a shortage of nursing home beds that is the problem; it is usually a shortage of funding.

You are quite right. The problem is one of the availability of real, funded nursing home beds.

We had a submission from a representative of the health councils, who posed a question about health board boundaries and structures and suggested that, for some acute services, it may be more appropriate to consider provision in bigger areas. The converse of that view was the suggestion that, for other services, it might be more appropriate to consider different ways of delivering and holding funds accountable. Kay mentioned bedblocking, but that is not so much an issue of money being available as about money being inappropriately spent on people in the wrong type of facility. Does the BMA think that the provision of community care services would be better managed through one source to get better use and more accountability?

I will start with the first point about health board boundaries. After the acute services review, we are already examining the provision of services across health board boundaries and the development of the managed clinical networks. That is in its infancy but it is an exciting scheme that will enable us to deliver a better quality of care without there being any postcode-type health board boundaries. That is starting to happen now and we support it.

In answer to the second point, about community care, local health care co-operatives have just been established. We want to encourage dialogue between social services in the LHCC areas and the medical and health facilities in those areas to see whether some form of joint funding can provide better care where the focus is on a smaller community. It is early days yet, but there is certainly potential in that scheme. The BMA does not have a view on whether there should be a single source of funding, but there should certainly be increasing dialogue and co-operation at LHCC level.

Unfortunately, colleagues, our time is limited. We shall have a supplementary question from Margaret Jamieson and then a final question from Hugh. After that, we shall have to call it a day. If we have a burning desire to ask any other questions, we can write to you.

You mentioned the joined-up working of LHCCs and other agencies. I am aware that there have been pilot projects prior to the setting up of LHCCs. There was one in my constituency that involved GP practices and the social work department; the benefit to patients in the area was significant. The pilot project that I am talking about dealt mainly with the elderly, but it is clear that there would be benefits for people of all ages from the type of model that takes a holistic approach to health care.

We are enthusiastic about looking at examples of good practice. I am not sure which area you are talking about—

Newmilns.

Do you know about that project?

No, but I am certainly familiar with some of the pilot schemes. The BMA strongly supports such pilots and the use of flexible budgeting at LHCC level. Unfortunately, we have not yet seen much sign of a general willingness on the part of social work departments to allocate specific budgets and resources at that level. I know that most LHCCs have invited social work departments to participate, but the uptake has been variable and the willingness to allocate budgets has been minimal.

I remember, Margaret, that we discussed the progress of LHCCs some weeks ago. The "Designed to Care" structure is something that the committee will want to come back to and monitor, and we will want to consider cases of good and bad practice. I call Hugh to ask the final questions.

We probably do not have time for both my questions, but I would welcome written comments on my first point. I am concerned by the fact that the remoteness and the islands factor in the Argyll and Clyde Health Board area has not been properly recognised. That has been mentioned already, but I would welcome your further thoughts and suggestions on how that should be tackled.

More generally, some of your comments are based on a presumption that more money is needed. A number of people have made that point, but we are here to look at a report with specific recommendations, notwithstanding your aspirations to have more money for health care in Scotland.

You said that you welcomed the thrust of Arbuthnott. Given the fact that there might be no extra funds, do you think that the report, as brought forward, is the right report with the right recommendations, hitting the right targets and making the right contribution to the allocation of health resources in Scotland? Are there any significant changes that you think should be made to the report that have not been touched on?

The straight answer is yes. We welcome the Arbuthnott report, but it is a consultation exercise and we think that there should be some tweaking here and there. I hope that, before it is implemented, not as the green book, but with those points taken on board, we can improve on what Arbuthnott has produced.

Our major reservation centres on the indicative GMS. As Mr Chisholm said earlier, it is indicative and we will not necessarily implement it at this stage. Generally, the BMA welcomes the report, recognises that it takes forward the debate on allocation, and supports it. Consultation is on-going and we believe that that process should continue.

The issue of remoteness is complex, and I will be happy to answer Hugh Henry's question in writing. We are not convinced that remoteness has been properly addressed, particularly for GMS. The major differences in allocation between the comparable areas of the Borders and Dumfries and Galloway are quite clear. The Argyll and Clyde area is another example of incongruity, perhaps because of the fact that there is a huge, high-density population in Paisley, while the rest of the area is sparsely populated, which might produce spurious and inappropriate results.

The hospital sector is concerned that, without extra funding to oil the changes, there might be a distortion in funding between primary care and the acute sector, which could lead to difficulties in maintaining the service.

What is meant by distortion?

I shall ask the witnesses to expand on that in a further written submission. I am aware that our time and yours is constrained. Thank you for coming along and sharing your thoughts with us. As this is the first time that you have addressed the committee, I take this opportunity to record our thanks to your members for the incredible work that they do to promote all that is best in Scottish health. I am sure that we shall meet again. Thank you for your time.

I shall suspend the meeting for a few minutes until the minister arrives.

Meeting suspended.

On resuming—