Health Committee, 07 Nov 2006

Meeting date: Tuesday, November 7, 2006

Official Report 213KB pdf

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Health Board Elections (Scotland) Bill: Stage 1

I welcome the minister and Bill Butler to the meeting. As is our normal practice, I will bring Bill Butler into the discussion once the members of the committee have had an opportunity to ask questions.

Item 1 on the agenda is our third evidence-taking session on the Health Board Elections (Scotland) Bill. The Scottish Executive has given us a memorandum that recommends against further consideration of the bill. The submission provides the background for today's session.

The minister might want to make an opening statement before we move to questions.

As I have said to Bill Butler previously, I am sympathetic to the bill's concern about the level of public engagement with health boards about the planning and delivery of services. However, I remain of the view that the bill is not the way by which we will resolve that issue.

As we set out in our memorandum, we recognise the crucial importance of public engagement. That has been done in a number of ways and, in my view, we have made substantial improvements in an attempt to address some of the concerns. There are now senior councillors on national health service boards and there is a statutory duty on boards to involve the public. We have set up the independent Scottish health council as well as the community health partnerships, which each have a public partnership forum. Further, we hold the annual reviews of the NHS boards in public. There is a time issue involved. We should let those other measures bed in and allow confidence to build in the public engagement and involvement that they provide. I am pleased to note that many other witnesses to whom the committee has spoken have supported that view.

The bill is therefore unnecessary. It adds nothing to the programme. Indeed, it undermines the current clear and unambiguous lines of accountability from NHS boards to ministers and, through ministers, to the Parliament. I am of the view that local boards with a majority of elected members will inevitably lead to competing mandates at a national and local level and will create conflict that will detract from our core purpose of creating a better health service and improving health in our communities. I think that it would create a degree of uncertainty about who is accountable for what and, in future, health ministers might find it difficult to implement important national policies, which will have been debated in the Scottish Parliament. The bill could lead to the fragmentation of our national health service and undermine the founding fathers' vision of what the national health service should be. Further, it might result in a postcode lottery with regard to the provision of services.

I understand the points that Bill Butler makes about public involvement and I share some of his concerns. I would argue that the steps that we have taken need to be given time to bed in and I am sure that the bill is not an answer to the concerns that have been expressed.

The Scottish Parliament information centre gave us information about the situation in New Zealand and I have conducted a little bit more research in that regard. Have you had any discussions with representatives from New Zealand about how their system is working? SPICe tells us that there is clarity with regard to the objectives that have been set by the New Zealand Government and the district health boards that have been elected. The key issue that is of the utmost concern to you relates to the competing mandates. However, it appears that that issue can be addressed through the way in which the remit and the framework are set. Could you comment on the New Zealand situation, which is quite appealing to those of us who are interested in supporting the bill?

I have had no direct discussions about the New Zealand example. I have considered the legislation that was brought in by the New Zealand Government. Kevin Woods has some further detail about that. I have to say that, when one looks at the Crown monitors that have been put in place by the New Zealand Government to—in my view—control the directly elected health boards, I am not sure that that takes us any further, in terms of methodology, towards addressing the concern that Bill Butler raises about public involvement in the process. In New Zealand, it is almost as if they have created elected health boards and then created a system by which central Government can direct those directly elected health boards. By contrast, in Scotland, there are clear and unambiguous lines of responsibility involving the elected Scottish Parliament, the Health Committee and me as the minister responsible—every year, I write 2,000 letters and my department answers 1,500 parliamentary questions.

The key legislation in New Zealand is the Public Health and Disability Act 2000, which makes clear that the mandate that is to be given primacy is that of the national Government. The legislation includes a range of provisions to ensure that local health boards follow the direction that the national Government wants the health service in New Zealand to go in. For example, it specifies strategic plans and annual plans, all of which require a formal sign-off by the Minister of Health. There are also considerable powers in the act to enable the New Zealand Government to intervene if the performance of boards is deemed to be unsatisfactory in some way. Indeed, as the minister said, there is a specific power for the minister to appoint Crown monitors, who attend meetings of local health boards and have access to all their information. The act says that the three functions of a Crown monitor are to

"a) observe the decision-making processes, and the decisions of the board:

(b) assist the board in understanding the policies and wishes of the Government so that they can be appropriately reflected in board decisions:

(c) advise the Minister on any matters relating to the DHB, the board, or its performance."

Further, as you would expect, there are powers of direction and powers of removal at the disposal of ministers in that system. That gives you an indication of the potential for intervention by the national Government in district health board matters. The legislation incorporates a raft of control procedures and legislation to ensure that the views of the national Government are carried through.

In that case, where do you see problems occurring with regard to what you aspire to achieve and what the communities in Scotland aspire to achieve? The New Zealand system seems to involve clear objectives that would match the national priorities. I am not clear about where the conflict arises between your policy and what is happening in New Zealand.

The conflict lies at the heart of what Bill Butler's bill seeks to do. What is the point of having directly elected boards if the Government is simply going to establish processes that will control them? I would argue that the systems that we have currently involving elected leaders from local authorities, the Scottish health council and statutory duties to engage are much more effective and will deliver a greater sense of involvement than some other shift. Given that what is proposed is a bureaucratic arrangement as well as a democratic arrangement, and that it will double the size of boards in the process as well, I do not think that the bill would deliver what it seeks to do.

I go back to the first principle that I outlined. I share the concerns about the desire to involve the public more widely in the work of our boards. Nevertheless, I do not think that the bill is the right way in which to deliver that. The New Zealand example is a good one. On the one hand, the Government gives directly elected boards. On the other, because of the need to have a national health service for cancer, paediatrics, neurosciences services and the waiting times centre in Clydebank—all those big issues that are so important to our performance—we need a degree of central management of our national health service.

In your memorandum, under the heading of "Public Involvement", you refer to

"the Annual Reviews with all NHS Boards."

You state:

"These meetings will take place in public, scrutinise Boards' performance and ensure accountability for local communities."

Can you tell us how many members of the public have attended the annual reviews? Are the public given the opportunity to question the health boards or the minister about their plans and policies?

I cannot give you figures off the top of my head. The attendances at annual reviews have been widely variable. I recall that the NHS Tayside meeting was fairly busy although other meetings were not so busy. I will reflect on that and get back to you if we can provide information on that specific point. I am not sure whether we gathered people's names. The meeting in Glasgow a year ago was extremely busy with members of the public. I apologise for not having that information, but I can say that there was a good sprinkling of the local interested population.

There is also involvement of patient groups, who are, in effect, local people. That is now an integral part of the annual review process. Not only did we advertise the annual reviews; a part of the annual review process is put aside specifically for patients, patient groups and carers. That is an effective part of the process.

The Scottish public are not slow in coming forward with matters that they want to raise with either the Health Department or the minister, as I said earlier. Prior to devolution, the Secretary of State for Scotland received 1,500 PQs; we currently receive 2,000 PQs for health alone. There is also a greater involvement of elected members who represent the views of communities. So, there are other ways and measures that I think are equally effective in involving people in the workings of our national health service.

Some of the attendances at reviews have been huge and the interest has been such that we have had to televise them to be shown in adjoining lecture theatres.

In all the annual reviews, we now have the benefit of an independent commentary from the Scottish health council on the work that boards are doing to involve the public and patients. Part of the day is set aside to allow the minister to hear directly from patients and members of the public who have been selected by the Scottish health council to come and represent their views, rather than being invited to participate by us or by the health board. We think that that is a very useful way of hearing directly about local concerns. The issues that emerge in those conversations are then shared by the minister in feedback at the annual review meeting itself. There may well be issues relating to individual matters that people have raised, which we follow up with the boards.

It would be useful if you could get back to us with a bit more information on the annual reviews—for example, how many of the audience members are staff and how many are members of the public? Perhaps you can answer my specific question about whether the public are given an opportunity to question health boards and the minister at the annual reviews.

No, there is no such direct opportunity. However, I am sure that you and other members are aware that, as soon as the reviews are over, I go to where the public are sitting and have conversations that are not on the record. I have thought the idea through but, currently, I think that it would be difficult to do what you suggest. I go along to the annual review with the purpose of reviewing the whole of the workings of the board, from sexual health services and health improvement to acute settings, accident and emergency services and other such issues. I am not saying that I rule out what you suggest for future reviews, but the difficulty is that if we engage the public to that degree, there is the potential for the focus of the review to be moved around in such a way that the review is not a systematic assessment of the workings of the board.

I am not saying that the annual review process is perfect, but it is getting better as we go along. We have learned from the past how to do it better. I do not rule out what you suggest in the future, but I want to ensure that we protect the review's focus. Not everybody is interested in talking about sexual health or children's services. Not everybody wants to talk about best value, service improvement or patient journeys. I want to ensure that we cover all the workings of the board. Nonetheless, I believe that we must always seek to improve patient and public involvement in that process.

I am not sure how you can claim that the annual reviews ensure the accountability of boards to local communities if those communities cannot question either you or the health boards at these meetings. If, as you claim, the reviews aim to ensure accountability, surely the public should have the right to raise whatever questions they wish to raise.

With respect, the Scottish health council brings together 12 to 15 patients, carers and service users. Those might be children with special needs, carers, cancer patients or patients with diabetes. I think that that is a good engagement that takes the temperature of local community views on services. We have also heard from elderly people and elderly people's groups through the work of the Scottish health council. I will be able to demonstrate that in correspondence with you. We have been able to attract those people along for a significantly positive engagement on how they feel about their health service and the direction of health services. I have to say that we have received, on the whole, very positive responses from those engagements.

Those people are selected not by me or by the board but by the Scottish health council, which brings people to us to have those conversations. I think that that is quality time that then feeds through into the annual review process. We have sorted some problems out locally when we have had to, and we have reflected on some of the more systematic issues during the reviews. I hope that those will be resolved by the next time that I visit.

To paraphrase what someone else said, accountability is a process, not an event. We must remember that health boards hold public meetings every month to set out their plans and policies. They hold those meetings in public and there are rules about notice being given of the meetings. We have been trying to build on that process in a variety of ways. In our community health partnerships, for instance, the work of public partnership forums is extremely important in engaging people in the work of boards. That is all part of a process of developing the kind of dialogue that everybody around the table wants to see.

There is slight amusement about this exchange, as I suspect that our constituents have a very different notion of the definition of accountability. That may be where some of the issues arise.

Thank you for your opening statement, minister, which set out why you are not in favour of the bill. I agree that a lot has been done to ensure public involvement and consultation, which must have been done at great cost—I do not know whether you could put a figure on that.

As far as the public are concerned, consultation meetings are something that we go along to in the hope that our views will be taken on board. After the consultation, we like to see the ways in which our views have been taken on board. I think that the general public still do not feel that that has happened. You are engaging with more people, but I do not know whether we are getting anything other than what the health boards want to get across to us. At one of those consultation meetings, a health board member who was on the group of which I was also a member said, "I am glad to have you here. It is so good to be able to get our point across." We all felt that that was exactly the point of the meeting. So much expense is going into trying to get the health boards' point across, and there is conflict between the public and the health boards.

I would not dispute much of what you have said, but I am not sure whether there will ever be such a thing as perfect consultation. I strongly believe that we must endeavour to engage more, as we do on our strategies on coronary heart disease, cancer and diabetes, for example. We involve people in the process and therefore deliver a better service, but the system is by no means perfect. However, the question is whether the problem can be solved by having directly elected health boards. The suggestion seems to be that it would be like waving a wand and that, with a majority of elected members on the board, consultation would be perfect, everyone would accept that that was the case and engagement would be all that we want it to be.

I sympathise with the sentiment, but I believe strongly that the proposed solution will not address the concerns. Given the way in which you posed your question and described the situation to me, I am not certain whether it is your view that a directly elected health board would solve the problems. Attitudes might not change and there might still be an issue over whether people can get their points across in that environment. It is a big risk to take with our national health service. The bill is an attempt to address a concern, which I think that we share, through a mechanism that I am not sure will solve the problem.

I think that having elected people on the board is a risk worth taking. Last week, Helen Tyrrell, from Voluntary Health Scotland, said:

"the public have great capacity to make sensible, informed decisions about the vast bulk of local health service configuration, change and provision. We do not always credit them with enough of that capability and we must make all possible efforts to foster such participation".—[Official Report, Health Committee, 31 October 2006; c 3170.]

At our meeting the previous week, a councillor suggested that he was not sure whether primary care ought to be part of the NHS. There would be a great debate on a health board if more people on it had different opinions. The impression that we get when we sit in on health boards is that there is not an awful lot of discussion. When Dr Cumming gave evidence last week, he described the amount of paperwork that people are given before they go to a meeting. He receives the papers at the same time as those who sit round the table, but he just sits in and observes. They hardly have time to take in all the facts in the papers and often there is very little discussion. I cannot see what there is to lose by having elected members of the public on health boards. Vastly different opinions could be represented, which might be good because, as I have said before, if someone stays in Kinloch Rannoch—

Can you please formulate a question to the minister?

I have to explain why I think that there might be a better discussion if different people are elected. We have different opinions.

A question.

The question is that I still cannot see why it would not be good to have members of the public on the board. If someone lives in Kinloch Rannoch and their services are to be provided in Dundee, they can give their opinions on the transport difficulties, lack of services and so on. Those issues might not be in the head of someone who lives nearer to Dundee. The same is true for Glasgow if someone lives up the west coast. I cannot see where the minister is coming from and why he thinks that elected boards would be so detrimental.

To be fair, I think that I said that we must balance the risks. I am not sure whether we will ever get to the holy grail of consultation that Jean Turner has described. I am not sure that we can invite someone from every town, village and hamlet in every part of Scotland to be democratically elected to our health boards and therefore make decisions. We must bear in mind the significant risks of fragmentation and confused mandates. We must consider the possibility of postcode delivery of services. We must also consider the manageable size of a board and how it conducts its business. Those are significant challenges for us.

With due respect, I am not sure that directly elected health boards, which you seek to impose on the service, would solve the problem. Jean Turner and I disagree on the matter. It has not been my experience in the past and I do not think that it would be the experience in the future that such a step would solve the problem. The big risk is that the proposal could fragment the service and destabilise the progress that we are making in Scotland on our national health service. It would also confuse mandates.

You summed up the situation by saying that there is no such thing as perfect consultation. However, it is not just about consultation. Although it is possible to spend an awful lot of money consulting widely, the problem often lies in how the responses to the consultation are evaluated. There is often no right or wrong answer; often an answer suits some communities but not others. What is your opinion on how directly elected boards could make a difference to the evaluation of the consultation process?

To be honest, I am not sure that directly elected boards would make a difference. My concern would be that we end up with sectional interests being represented—the people who speak up for children's services, sexual health services and mental health services, for instance—rather than those who might speak up for big, visible issues relating to some of the bigger decisions about the health service that have been made in recent times. That worries me.

Secondly, I would note the experience in other sectors. For instance, schools have been reconfigured and invested in. Some new schools have been built, while others have closed. Primary school estates are reducing because of the falling population in that age group. I am not sure that what people say about how a directly elected local authority deals with consultation responses on education closures is any different from some of the concerns that folk have about health.

When things go well for a community where there has been change in the health service, the vast majority of folk are silent. They accept the decision and just think, "That's very good, thanks very much." The communities that are less inclined to support a change will make more noise. What does that do? I go back to the point about being sympathetic to the idea that we need to involve people more in services and in moving those services on. My argument is that we have been doing that for four years.

The diabetes plan, the coronary heart disease plan and the cancer plan all involve patients, carers, families and community representatives. The bill offers another way of doing that, but my view is based on the balance of risk in the potential effects of the proposed legislation. It is also a matter of allowing some of the things that we have been doing to bed in more effectively. I think that we can deal with things in a different way.

Under the heading "Delivery", your written submission states:

"This Bill would make no difference whatsoever to the achievement of this principal purpose and would, potentially, distract Boards through the implementation of this Bill's proposals."

Could you elaborate on what you mean by that?

That can be exemplified by a number of issues. Could we lose the opportunity to plan services regionally? We are delivering as many services as we can as locally as possible, correctly in my view, but it is also necessary to specialise. On occasions, the location of specialist services and equipment must be determined on a regional basis. If a democratically elected board wants to keep a facility in a certain location, how will that affect the roll-out of national services? That potential effect of the proposed strategy worries me greatly. There are also issues around national services. Delivery could be affected. The priority that we in the centre place on policies that the Parliament has agreed would undoubtedly be put at risk, with people in different parts of the country seeing things differently.

One example might be investing in a magnetic resonance imaging scanner—an MRI scanner—versus investing in a sexual health clinic. How do we measure the importance of those choices for communities? How do we ensure that we have a national service? The national health service is funded by taxpayers equally in every part of Scotland. The effect of the bill might be to vary that service around the country, which would mean things being done in a different way in different areas and the risk of losing some of our sense of an integrated, collaborative health service, with its partnership working. That would be a substantial risk under the bill.

You mentioned dual mandates and the vested interests that could almost be said to exist already on health boards, which can cause a lot of concern. The British Medical Association's agenda—the doctors' agenda—is expressed on health boards; the royal colleges have their agenda expressed on health boards; general practitioners express their agenda; consultants express their agenda. I am not yet convinced by the evidence that we have heard about the idea of creating a public, elected voice to balance all those agendas.

Do you accept that there are big problems with vested interests on health boards, as they are perceived by the public? The employees of boards vote things through, which is a perceived problem. People perceive that the public agenda is not being articulated as effectively as it could be. That is a real problem.

There are lay members of boards and local authority leaders or senior councillors serve on them. Those people do not have what you describe as vested interests, so there is a balance in the structure of boards.

The matter is also about information and how we exchange it. For example, when the Kerr report was in its formative stages, there was engagement with patients about the proposed planned care centres, which would be able to offer 99.9 per cent delivery of services because they would not be interrupted by the need to provide accident and emergency services. The A and E services would be provided separately in so-called hot hospitals, which the Kerr report calls level 3 hospitals. People said that that was a good idea, and similarly they agreed that it would be a good idea to take more diagnostics into the community. During that engagement, people genuinely bought into those strategies.

The problem arises when we try to translate that into communities. As you know, I have many debates with communities throughout Scotland. Often, people buy into the concept but they say, "No, but not our hospital. Can we do it there, please, but not here and now? Can we do it later and do it over there?" Whether we call it a vested interest or not, boards take time to provide information, to consult and to prove that they have consulted through the Scottish health council. One problem is that, by the time we get to discussions with the community, opinions have been too strictly formed and there is an immediate counter-reaction to the proposals. I am not sure that that would change under directly elected boards.

As Duncan McNeil said, the medical bodies are represented on the boards, but there are also lay members and elected members who should act as a counterweight.

That is the point I am getting at—I do not know whether there is a counterweight, although, having heard the evidence, I do not know whether Bill Butler's bill would achieve what we want.

To put the matter in another way, only one of the groups that I mentioned does not have a veto. Boards cannot proceed with their plans unless the doctors and the royal colleges tick the box, but they can proceed without the public's consent. As well as a veto, the other groups have a greater say and they are more able to make their argument because they are supported by health board officials and academic studies. It is difficult for lay people to get support to present alternatives on behalf of the communities they represent, so there is an imbalance. I am not convinced that the bill would correct it, but there is an imbalance that acts against the communities that we seek to serve.

With due respect, I do not agree that that the lay members of boards are not informed and not tooled up with the arguments. That is an assumption too far.

I believe that, when we explain strategies to communities and small groups of patients and carers, we begin to get a sense of buy-in to what we are trying to achieve. We will never have a perfect situation. There will always be an imbalance between the weight of the community and that of someone who has been working on proposals for service change for 18 months.

My job, at the centre, is to adjudicate. My job is to test the board's ideas to destruction, to make sure that they fit with the community's interests, that lives will not be put at risk, and that the strategy is the right one for the future. It is my job to ensure that there is a balance so that, in exchange for a service change or reconfiguration, there is investment in primary care in the community, and that, for every development in acute care, there is work to improve health and well-being. To me, that is a directly accountable process.

I believe that, with the bill's proposal of an elected majority plus one, we are in danger of turning that clarity into ambiguity. It is my job to be held accountable in the Parliament and elsewhere for any decisions I take on health boards' proposals for service changes. I listen to communities, balance the arguments and make decisions. On many occasions we have changed health boards' proposals, and we will continue to do so.

I have to say that I am not sure about the bill, but many interesting points have been raised this afternoon. All of us—including, I know, the minister—have been involved in situations in which whole communities oppose certain health board proposals. Indeed, I was involved in a case that required the Scottish health council to be brought in and the consultation to be repeated. The end result was still opposed by a vast majority of that community.

I am not convinced that the bill is the right way to address this matter, but it is clear that no one has got it right yet. Can you suggest any alternative approaches that we can consider?

I am not sure that any community in Scotland willingly undergoes changes to its service. My task is to decide whether such changes bring added benefits to the whole community.

I should point out that the public, local government and parliamentarians bought into the principles of the Kerr report, because they realised that we needed to shift the balance of care; to improve diagnostics; to do much more about health improvement; and to establish, for example, planned elective centres and emergency level 3 centres. However, such an approach requires a tough decision-making process. I am quite often told, "You'll have blood on your hands" if I take a certain decision. Well, after reading information and evidence from health boards that show, for example, that a particular service is unsustainable and that it might well put lives at risk, I know that there will be blood on my hands if I do not take the decision. We face real challenges in this matter, which brings me back to the need for a clear and unambiguous system.

I read all my press cuttings. I know what happens to the decisions I make. I know where the accountability lines are drawn. In response to Nanette Milne, and with all due respect to Bill Butler, I do not know whether his approach resolves any of those issues. Are we saying that the service should no longer be national, that we should get rid of regional strategies, and that everything should be allowed to stagnate? Over the past 10 years, day-case rates have increased markedly, but such an increase could not have happened without a change to the nature of our acute sector. Accident and emergency and trauma medicine have improved massively in the past five years, but there is no way we can retain such skills in every location. Moreover, the role of the Scottish Ambulance Service and paramedics has changed.

Those are the major issues that we face and, sometimes, communities, individuals, families, friends and relatives have not caught up with some of the changes that have been required to deal with them. Our job as parliamentarians and policy makers is to take some of those tough decisions. In my view, the lines of accountability are very clear, because I feel it every day.

Can you think of any situation in which a health board backed away from its preferred option because of public pressure during the consultation?

Significant changes have been made to services in Glasgow, particularly children's services. In the Borders, due to significant public pressure, investment was made in other services such as the establishment of a dental centre and outreach facilities for elderly care that would not have been provided under the scheme that had been proposed. We can reflect and come back to the committee on that question.

It would be a useful exercise.

Perhaps another example would be the cancer services in Monklands.

The public perception is that although the consultation takes place, the health board gets the result it wanted in the first place. It would be useful to hear of examples when that has not been the case.

I have a very quick question. Did the 2003 Labour Party manifesto contain a commitment to consult on directly elected health boards? If so, why has that consultation not been carried out? If you agreed at the time to carry out that consultation, what has changed since then?

I am not sure whether that question is in order, convener. I thought that I was here as the Executive's Minister for Health and Community Care rather than as a Labour Party member. However, I can clarify that, because Bill Butler produced his bill and carried out a consultation, that manifesto commitment was met.

That is interesting. I would have thought that a manifesto commitment would be for the Executive to carry out, but the Executive has not carried it out. Perhaps you will answer my second question: when the commitment appeared, were you signed up to it?

Of course—we signed up to a consultation.

Has your view changed since then?

My view on a consultation was that we should have one.

Has your view on the principle changed since 2003?

Convener, I again seek your guidance. The manifesto commitment was to consult, which has been done via Bill Butler's bill.

So you did not have a view about the issue in 2003?

My view was that we should support the manifesto, which said that we should consult on the idea.

Perhaps that debate could be carried on in a different forum. There might be another way and a better place in which to raise the issue.

Bill Butler has the next question. I know that it is difficult for members who bring members' bills to the committee to have to sit and listen to all the questions before they get an opportunity to speak. However, the minister is here until 3 o'clock, so you have a bit of time.

Thank you, convener. I am grateful for the time that has been allotted and for the minister's appearance. He made a clear statement about the dangers, concerns and issues that he feels arise from the bill that I have put before the Parliament. I am pleased that I have been able, unbeknown to me, to fulfil an Executive pledge by carrying out the consultation on the bill—I take that as a plus.

I have a few questions about accountability. I guess that we will not agree, but I will ask my questions anyway, for the record. Minister, despite the apprehensions that you detailed in your written submission and in your evidence this afternoon, do you accept that, under the bill's stated provisions—those that are actually on paper—NHS boards would remain accountable to ministers and the Scottish Parliament?

I do not believe that that is the case. The present unambiguous relationship would change sizeably. As I said, if a board made a decision that was either outwith or against national policy, that would be a difficult issue for the minister. Where would the decisions lie if we had boards with a majority of members who were directly elected to them? That would leave the public confused. If an elected board thought that its allocation under the Arbuthnott formula was not appropriate and decided to run a deficit, it could tell me that and say that it wanted me to sort out the matter. How would I maintain my powers and my position as minister? The public would be confused about who controlled what. I believe genuinely that those issues would arise. Unless we had the New Zealand model, with controlling features in the process, ministers' powers and responsibilities would be undermined.

I knew that you would not agree with me, but that is a slightly puzzling answer. Are you saying that amending one particular aspect of the National Health Service (Scotland) Act 1978 to make the simple majority of members on boards directly elected would undermine all your other powers? Quite frankly, it would not.

I said that the bill would undermine the clear and unambiguous nature of the current relationship.

But not the powers.

I would need to speak to the lawyers and come back to you on the legal point. The powers under the 1978 act have rarely been tested, which is part of the problem that we have.

I can comment on the powers. The key power is the power of direction, which is in section 2(5) of the 1978 act. It has never been used, so the legal boundaries to the exercise of the power are not entirely known. If the proposed changes took place, it might be necessary to consider carefully whether supplementary measures that were akin to those in the New Zealand legislation were required, if your objective is to ensure the primacy of ministerial accountability.

It is not my objective—it is there in the bill. Do you accept that, under the terms of the bill, boards will still be required to deliver national targets, guarantees, strategies, initiatives and policies?

I almost feel like saying, "I refer to my previous answer". I accept that what you have stated is the statutory position, but I believe that the bill undermines lines of accountability, public understanding and the clear, unambiguous roles and responsibilities of ministers.

We have a difference of opinion, which is not surprising.

In page 3 of the Executive's submission, there is talk of

"wilful refusal of a Board (or Boards) to implement nationally agreed policies/programmes",

which

"may permit the ‘postcode delivery' of services."

Do you accept that "‘postcode delivery' of services" is a very loaded phrase? Surely we are talking about boards responding to local needs—which they do at the moment—within the national guidelines and framework that are laid down by the Parliament and by the minister. If boards did not respond to local needs, they would merely be administrative units.

I believe that the bill shrinks ministers' opportunity to ensure that national policy is delivered. I refer, for example, to national policy on cancer, coronary heart disease and mental health. I expect those to be national priorities that are delivered at local bases. As I said earlier, this is a national health service that works on an integrated, partnership basis in Scotland. Anything that gets in the way of that could lead to postcode prescribing.

For example, I strongly believe that if a board decides to buy a new MRI scanner because it wants to do something different and to do better than the target, but it takes the money for it from sexual health, children's health or mental health services, its actions undermine the national service. We set national standards for health because, as I have said, the taxpayer in Shetland pays the same as the taxpayer in the Borders, Edinburgh or Glasgow. We make certain core commitments to every patient in Scotland on national waiting times, access to services and so on. I strongly believe that there is the potential for the bill to undermine that.

Surely the core commitments can be met and flexibility left for NHS boards to consider the local needs of very different areas.

With due respect, that happens every day in primary care in our health service. Certain primary care targets have been set for health improvement and access to GPs and members of the local health care team, but local boards have a very wide playing field to respond differently to ill health and sexual health issues in different parts of Glasgow, let alone different parts of Scotland. That flexibility exists.

Surely the bill does not change that.

It has the potential to change it. I return to the balance of risk. With due respect, I have not said that the bill will or will not change things; I have said that there is the potential for it to do so and I have asked whether that is a risk worth taking. In my view, it is not.

That is clear.

I will move on to public involvement. Having followed the previous evidence-taking sessions, you will have been pleased to hear that all those who have given evidence have welcomed—as I do—the reforms of the past few years to encourage greater public participation. In its submission, Voluntary Health Scotland stated:

"While significant progress has been made by local NHS Boards towards integrating PFPI in the development and delivery of local health services, it is the experience of Voluntary Health Scotland that progress could be accelerated by introducing"

directly elected members. Why do you regard patient focus, public involvement and other forms of participation as incompatible with boards' having a directly elected element?

In recent times we have introduced a number of measures relating to the way in which we work with patients, patient groups and carers. Those measures should be given the opportunity to bed in and to develop further. The patient focus and involvement in CHPs, for example, is at a very formative stage. Anecdotal evidence and the evidence that I have received in annual reviews indicates that CHPs are settling in extremely well. The bill is not appropriate at this moment in time as it would run the risks that I have described. I would prefer the work that we are doing to play out more fully.

The coronary heart disease strategy and the diabetes strategy show that patients and carers have for years been working together at the heart of policy making to make a difference. The current system could achieve that locally and nationally. We disagree about whether the bill would make a difference to that.

My strong view is that we should focus on patients rather than on elections to boards. I would prefer the patient involvement processes that we have to bed in than to change the system to have directly elected boards, which would upset some of the progress that we are making.

Is your view based merely on timing? Are you saying that a directly elected element would be complementary in the future or simply that you would not agree with it at any time?

I would never say that I would disagree with direct elections at any time in the future. I am saying that, as we crash down waiting times from 18 months to 18 weeks, as we improve survival rates from coronary heart disease, stroke and cancer and as we deliver on our mental health strategy, which is seen as an example throughout the world, and on our health improvement work, we are doing some really good stuff. I am not sure whether throwing the bill into the great balance that we have in our national health service would break that potential apart. I worry about that.

I agree that we are doing some really good stuff. That is absolutely clear from the figures, some of which you referred to. Given that, are you disappointed that, according to a survey that the Executive commissioned in 2004, 73 per cent of the public feel that they have little or no influence over how the NHS is run? That is a rise in dissatisfaction of 16 percentage points over a survey in 2000.

When we make changes in the health service, it is sometimes really challenging for people like me and for communities. I do not know what the surveys say about how the Scottish Parliament, the Executive or local government works and I am not sure how we fit into the picture.

I return to the point that we are doing good stuff. We are trying to do more on patient focus and public involvement and we should allow that to bed in more before the balance of risk is accepted and we decide to have directly elected boards.

How long should we wait?

I say with due respect that I do not know. We will examine how boards, the regular engagements board, the Scottish health council, which is at its formative stage, and the public focus and involvement in CHPs are working. I would prefer to focus on service delivery and engagement with the public than to drop in some arguably risky legislation. Given that, I cannot suggest a timescale. In due course, we will all have a sense of whether the system is working.

Are you saying that if an appropriate time arrives, you will not be against the principle behind the bill?

At this moment in time, I am against the principle that is behind the bill because it would not be right for our national health service. The case has not been proven and high risks are associated with the bill.

That is clear. Thank you.

The Executive's submission says that the proposal's costs

"could be significantly higher than those set out in the Financial Memorandum"

and

"could be in the region of £5m."

The financial memorandum gives costs from £1.2 million for a turnout of 30 per cent to £2.4 million for a turnout of 60 per cent. They are based on experience in Stevenage. Mr William Pollock of the Association of Electoral Administrators said last week that

"the cost of an all-postal ballot would be anywhere between £1 and £2 per elector",

although, to be fair, he said that there are

"many other unknowables."—[Official Report, Health Committee, 31 October 2006; c 3175.]

What is the Executive's rationale for being so adamant that the financial memorandum significantly underplays the cost?

We looked at a number of evaluation studies on different locations: Stanley division of Durham County Council; two wards in Telford and Wrekin Borough Council; Walker ward in Newcastle City Council; Hunstanton in Kings Lynn and West Norfolk Borough Council; and East Downham in Kings Lynn and West Norfolk Borough Council. We considered the total number of electors, the turnout and the resulting cost per vote, which was £2.53. We applied the turnout for the Scottish Parliament election and local elections of 2003, which was 49.4 per cent. It resulted in a bill of £4.83 million. The turnout for the Scottish Parliament election in 1999, which was 58 per cent, gave us £5.67 million. We also considered the 72 per cent turnout at the United Kingdom general election in 1997. We sought to consider postal ballots over a wider sweep and the cost per elector. I am happy to share those data with Mr Butler.

I am grateful for that.

That would be useful to the committee.

We could argue about figures all day, but I do not intend to. Even accepting the £5 million, is that too much to spend, out of a budget of £10-plus billion, to introduce an element of democracy?

If I thought that that £5 million would be well spent, it would not be a problem for me.

Okay, that is clear. I have one last question. If you cannot answer it now I would be grateful if you would forward your response to the committee, and to me, if that is permissible. Will you give the cost of the greater public participation reforms that we have been talking about? Will you outline how much each of those reforms cost in total and per annum, or over the number of years that they have been in train?

I do not have that information to hand, but Kevin Woods will be working on it.

We will try to get you an estimate of it.

That would be handy.

The minister has committed himself to corresponding further with us, so I thank him for his attendance. That was the penultimate evidence session on the bill.