I welcome the panel of witnesses.
Scotland Patients Association is a registered charity that exists to help people who have difficulty in achieving what they are trying to achieve. We do not wish to demolish the NHS or do anything to it; we are complementary to the NHS. We have been going since 1981 and our head office is in Stirling. This is the first time that we have appeared before the committee. The next time that we do so—if there is a next time—we will submit to you something in writing. I apologise.
That is not a problem; it is good to see you here. It would be helpful if one person could act as the principal speaker for the Scottish Association of Health Councils, with the other adding to what has been said, and Margaret Watt could represent Scotland Patients Association.
We were consulted on the proposals for the bill and we have no difficulty with the timing of the consultation or the opportunity to comment on the bill, which we have done. We have been happy with the process.
I concur with that.
Last week, we heard from general practitioners how well they had been consulted and involved in the process. The question that I asked of them last week is perhaps more properly directed at today's witnesses. I am interested in finding out how the patients have been consulted throughout the process. How effectively have the patients been consulted?
I can comment only on behalf of the Scottish Association of Health Councils. The committee will be aware that there are 15 local health councils in Scotland, of which our association is the membership organisation. The members of the local offices of the health councils are drawn from among their local communities and patients.
Does Margaret Watt want to expand on that?
No, thank you.
Okay. Does David Davidson—
May I pursue my question, please?
Sorry. Yes.
I am surprised that Scotland Patients Association does not want to comment. My question concerns the way in which the patients—the end users and the consumers—are involved in the process. Are we just implementing an agreement between employers and employees? Where are the patients in this? I thought that Scotland Patients Association would have a comment to make.
It is difficult for people to understand fully what is going on with health issues; it is difficult for people to take on board all the changes. In fact, some national health service staff do not understand the changes.
From the patients' perspective, do you feel that the consultation process has been flawed or non-existent?
The patients want to know only that they can go to the doctor, full stop. They do not want to be bothered with all the different changes. People understand no more than the rudiments of the NHS; they do not understand how the rules and regulations work. They want only to see their doctor when they need to and they do not understand why they are given appointments a week, a fortnight or three weeks away.
May I pursue this line for a little longer, convener?
Is David Davidson's question on the same subject?
I have a question on the same topic.
You may ask your question, Mr Rumbles.
One of our primary tasks is to check up on the consultation process on the bill. It strikes me that the key player in the process is the patient, who is the end user. Perhaps I do not understand your organisation properly—
Possibly.
Perhaps you could enlighten me, then. I find your comment to be strange, given that your organisation is called the Scotland Patients Association. Do you not believe that consultation is important on this area? Is not it the key issue as far as patients are concerned? If patients are to use the new service, surely they should have had an input into it.
The Scotland Patients Association does not have members as such; we can voice only the opinions of the people to whom we speak from time to time. We have no members; we have only our board. If someone has difficulties with the NHS, they can get in touch with us. That is the only basis on which we can give you information.
Can you suggest to the committee who could give us the patients' view?
The patients.
How do we speak to the patients?
Through the media?
I would like to move on now. I appreciate that your organisation has not been before the committee before. I think that it is a bit of a learning experience for you and, perhaps, for the committee. We will address the matter in due course.
I would like to take a different approach and ask what was done during the consultation process to raise awareness of what will be done. I accept that that would be difficult, given that the negotiations were somewhat difficult, but what opportunities will patients be given to make them aware of the possible implications of the GP contract?
The local health councils have a network that involves volunteer members of the public who have become extremely knowledgeable on issues such as this. Certainly the problems arising from the bill and its implementation were discussed by my health council. The health council movement represents a public patients' network. In different areas, there are different biases towards the public. That is a reason why the system should be much more inclusive across the board.
I suggest to the Scotland Patients Association that, if you wish to be more prepared for certain questions, it might be useful if we send them to you so that you can submit the answers to us in writing before our next meeting.
That would be excellent.
In fairness, it might be useful for us to give advance notice of certain questions to people who are not used to giving evidence to committees.
The Scotland Patients Association is more of an advocacy group for individuals who have difficulties, rather than a sounding board throughout Scotland.
Yes, it is.
I want to explore the issues about opting out of provision of the so-called enhanced services. Do you have evidence on practices in Scotland that are likely to opt out of the provision? Will you also comment on the out-of-hours services?
We welcome many things in the proposals, but the out-of-hours services are in the area of greatest concern to us, which is the overall capacity in the system to deliver. If practices are able to opt out of providing certain services, including out-of-hours services, we understand that it will be down to the NHS boards to provide for the services so that people will still have their entitlement. However, against a background where there appear to be GP vacancies in Scotland, there is a shortage of new entrants to the medical schools who are willing to go into general practice. Where are the NHS boards going to get that extra capacity to provide the services that local practices might decide to opt out of?
I hear what you are saying, but I would like to go a stage further and ask whether you have evidence of the number of practices that are likely to opt out?
I feel a confession coming on here.
I was going to say that I do not have any knowledge of what the situation is at national level, but Dr Adamson might be able to speak about the local level.
As far as the local situation is concerned, we have evidence—
Where is local?
Local to me is the Highland NHS Board area. There are big issues in the Highlands concerning the services because of the rural problem. The situation will depend on how the health boards view the matter. A considerable number of practices have already stated that they will opt out of providing out-of-hours services.
Can you give us a figure for "considerable"—a number of practices or a percentage?
I would prefer to be completely sure of my facts. I can provide that information early next week, but I would prefer to be absolutely certain before giving you a percentage.
I understand.
I have a supplementary to Helen Eadie's question about enhanced services.
We are concerned about enhanced services generally; for example, where they will be provided and their accessibility. Equity of service provision throughout the country is another issue. All those issues concern us. It all comes down to the capacity to deliver the enhanced services. Without having specific details of the services that are likely to be problematic, I cannot make specific comments, but we are generally concerned about the delivery of enhanced services, about access to those services—patients might have to travel—and about when the services will be available. Another concern is that some enhanced services might have to be provided by NHS boards rather than by communities or practices.
That applies to additional services as well as to enhanced services.
The British Medical Association told us last week that we have to make changes to attract doctors and to sustain services over the next four or five years. I get the feeling that we have been here before with such agreements. We employed similar solutions in acute services, by reducing working hours and developing specialties, for example. In this case, we see the potential for GPs to move into specialties, attracted by additional finance. GPs may be attracted into increased private work. A consequence of the agreements might be that we compound the problem rather than solve it. Do you have any sympathy with such views?
We certainly have sympathy with such views. The focus at the moment is on solving problems in recruitment and retention of GPs, against the background that we outlined earlier. We would like the programme to be more balanced. It should address not only the immediate problems of recruitment and retention, but the underlying capacity problem. We do not want a simple reshuffling of existing resources because that would create shortfalls in other areas. We would be more comfortable if there were a fundamental redesigning and streamlining of primary care provision involving greater use of practice nurses and local pharmacies. That should be underpinned by the use of information technology to reduce paperwork and to ensure faster appointments and referrals. We would hope that that would lead to, for example, quicker access to the GP of one's choice and to longer consultation times. We would also like a greater number of training places to be funded by the Scottish Executive, which should make a conscious effort to encourage students from overseas not only to study at medical schools in Scotland but to practise here.
You have not had sight of this, but in his letter of 8 September the minister addresses in part the issue of moving
I am trying to envisage a situation in which someone lives in a rural community and is the known general practitioner, but has opted out. In those circumstances, what do people do if an emergency arises in the area? Have you held discussions in such communities? In the remote area that the committee visited—which was not particularly remote—many professionals, such as midwives, complained that there are not enough of them to do the job. Have you received any feedback from remote communities about their concerns about the general practitioner structure breaking down because GPs have said that they will opt out?
Such concerns have been expressed. Many areas are starting to be more open about asking what out-of-hours provision people want. Attempts are being made to assure the public that there will be cross-disciplinary out-of-hours provision as well as GP provision. However, it will always be a problem for people to get a commitment.
Many people cannot opt out, even if they want to.
Yes.
Do the health councils believe that the bill will have a positive or a negative effect on rural practices and, especially, on patients in rural and remote areas?
I wonder why the question has been passed to Dr Adamson.
Patients in remote and rural areas already have concerns about equity of care, because they already have distinct problems in accessing services. Transport problems are associated with providing additional services in one practice in an area that is 100 miles long. There is concern that people might not have access to additional services, let alone enhanced services.
Has the Scottish Association of Health Councils considered how it would like the core part of the contract to be delivered in rural areas? Might contracts in rural areas need to be different from those in urban areas?
The association has not really addressed that issue, but it is being addressed by GPs from rural and remote areas. They probably have a good perception of the problems, but we would be happy to comment where appropriate.
Will you liaise with that group of general practitioners?
That is already happening in some areas.
In paragraph 1.3 of your submission, you ask:
It is not clear to me from the document whether that funding will come from the MPIG—if I may shorten it to that—or the Scottish allocation formula. I do not have enough detail on that. Although we are prepared to admit that single-handed practices, as many induced practices are, should be phased out, that would have to take quite a long time. The problem is on rather the same level as the problem to do with staff capacity. There will be a period in which those practices must continue. Otherwise, there will be no provision for patients in some areas, especially rural areas.
Is your plea for a sustained funding package as an interim measure to ensure stability in service access in those areas?
Absolutely. We are well aware that, as there are problems with single-handed practitioners, it is better that they are part of a consortium. However, yes, I would make a plea for sustainable funding as an interim measure.
If I may pursue that point, I am interested in the response of patients, particularly in the Highland and Islands and in the remoter areas, to the minimum practice income guarantee. Last week, we heard evidence from the BMA and from the general practitioners that they understood that the MPIG would cover the induced practices scheme. That was what they understood, but they had not seen the regulations because those are being worked on. Is there concern among patients in the islands, especially in single-handed practices, about the fact that we have not seen the detail? We have heard the GPs' concern, but is there concern among patients?
There is extreme concern among the public and patients in single-handed practices and in practices that are in the induced practices scheme. I could give examples of that.
The response of the general practitioners was that 79 per cent of GPs UK-wide—they could not give us a figure for Scotland—were in favour of the agreement. My concern rests with the fact that the patients in the remoter areas of Scotland may not have had a full input into the consultation process. Do you think that patients in remote areas and in the island practices have had a chance to feed in their grass-roots concerns to the Scottish Executive?
There was no consultation with the public and the patients over the GP contract, which is not the same thing as the bill. It is not really appropriate for the public and patients to be in negotiations on GP contracts. I do not think that that was required. However, public and patient consultation is required on the implementation issues that are involved with the bill.
I was going to leave it at that point but, having heard that response, I want to continue. You said that it was not appropriate for there to be consultation on the contract, but you emphasised that there should be consultation on the application of that contract. However, those two items cannot be separated. If the Parliament gets it wrong when it agrees to the bill, we cannot then go back and unpick it. We cannot then say, "Well, actually, it was the application of the contract that we were interested in." Do you see what I am getting at? The two things are absolutely linked together.
Yes, but the document makes it plain that the negotiations on the contract are separate from the bill.
But the regulations implementing the contract have not even been published yet.
A point of concern that we had is that paragraph 40 of the policy memorandum to the bill states:
That might be because we are in the odd position of dealing with a bill that in some respects adopts a commercial contract.
The policy memorandum sets out the Executive's position. You are not the Executive. That is why you are giving us evidence from your perspective and that is why we are questioning you. I was going to question the minister about paragraph 40. I always focus on consultation with the end user and it seems to me that you are saying—as I understand it you are the primary focus for patient input and that is why you are here—that because the Executive has published paragraph 40, thereby closing the consultation avenue off, you have decided not to go down that road either and to focus on something else. Is that correct?
It is correct in the sense that we believed that the agreement was a fait accompli and that we would have to focus on the consequences or the implementation issues arising from the agreements as part of the GP contract.
This might be something that you cannot answer, but do you know how many practitioners or how many practices are in the inducement payment scheme? It would be useful for the committee to know that.
I think that we heard that it was about 80.
I cannot give the answer right now, but we could find out.
I was just asking into the air to see whether we could find out about the problems in this area and how many practices we are dealing with.
My question is along the same lines as the previous questions. You are obviously aware that the bill is to facilitate the implementation of an agreed contract. However, the fact that we are going through the legislative process gives us an opportunity to consider the bill and the contract and to consider whether amendments would be beneficial. Would you like the bill to address changes to the structure of general practice, possibly through amendments?
You have 10 seconds to answer the question. If the question has really stumped you—I do not mean that in a rude way at all—we could perhaps ask you to come back on it after greater reflection. My colleague was just making the point that we are not stuck with what is there just now.
You have heard from previous members of the committee that we have concerns over how the contract has been agreed by the Government, the Executive and general practitioners. The committee has a responsibility to try to ensure that the bill improves the provision of general practitioner services in Scotland. I accept Dr Adamson's point about public consultation—although I do not necessarily agree with it—but I still feel that the committee must pursue whether there are areas in which the service might be improved. The witnesses will understand that the public are sceptical about the claim that they will notice an improvement when they go to see their general practitioner. Are there any openings for amendments to the bill that might improve the service?
We have talked about the improved services for patients that the bill will provide and about the importance of quicker access to GPs, longer consultation times and quicker referrals. The wording that I used was that I would like the bill to be accompanied by a fundamental redesign and streamlining of primary care provision. You have put me on the spot by asking how we could achieve that. I would like to respond to that question because it is an important one.
That would be useful.
My question is about whether the new contract strikes the right balance between local and national needs. On the one hand, there are concerns about keeping the result of the negotiations on the contract intact—there have been difficulties with that—and not allowing the contract to unravel but, on the other hand, the deal will really have to be struck and signed locally. What balance should there be in terms of local variations? Are local variations a good thing for patients and, if so, how far should those variations go?
Undoubtedly, local variations should exist and health boards will have some flexibility, but there must be guidance to ensure equity.
How can that be achieved?
That is another question that requires notice.
Should there be monitoring to ensure that local variations are allowed in the best interests of patients but that the framework of the contract does not unravel?
We welcome the fact that practices will be rewarded relative to what they deliver and that the measures of that will be qualitative as well as quantitative. Our submission expresses disappointment that the monitoring regime—for want of a better word—will not be mandatory. We would like patients, as consumers, and local offices of the Scottish health council to be actively involved in the monitoring of practices' performance. That would be helpful.
Although we advocate that the quality payments should eventually cover all practices, we recognise that some practices might have problems with implementation of the systems of assessment. We would therefore like there to be a provision that, in five years' time, all practices have to be involved in the quality scheme. However, it might be impractical to expect that to happen immediately.
When the GPs were before the committee, they talked about regional and local variations. However, earlier in your evidence, you said that you were uncertain that health boards would be able to step in and fill any holes in service provision. Have any of the health councils discussed with their local health boards how the boards would be able to play long stop if certain services were not offered on a local or regional basis?
I am not aware of any discussions on that issue between local health councils and boards. We have said that we are concerned that that might be the case and that we should be looking out for it happening, but at this point I am not aware of any such discussions.
In the hope of magnifying the responses that you will make to the committee on other issues, I wonder whether it would be possible for you to contact the health councils across Scotland to check on that point. You made the point strongly at the beginning of your evidence and it is in your submission. Could you get local health councils to make contact on that point and submit the results through you?
Absolutely; I am happy to do that.
Highland NHS Board asked the health council to run two pilot schemes on out-of-hours provision and how it could be covered with the bill in mind, and I suspect that similar schemes have been taking place elsewhere. However, they will be studies in pilot areas rather than definitive studies across the board area.
I noted that your evidence shows that you believe strongly that patients should be actively involved in the quality review of general practices. Do you have any suggestions as to how there could be an efficient mechanism for doing that?
I agree whole-heartedly. We are concerned that the service might become fragmented. We should consider the service from the point of view of the patient's journey. We are talking about access. That was what I was referring to when I spoke about trying to streamline and redesign the delivery of primary care. We are not just talking about the issue of the recruitment of GPs; we are talking about other ways of addressing such issues through the use of practice nurses and others. The way in which that is implemented and delivered needs to be planned carefully. That goes back to our call for longer-term issues relating to capacity and the planning and monitoring of service delivery to be considered not as an afterthought but bearing in mind the type of scenario that we are going to enter. We should be asking how services can best be delivered for patients, and the examples that the committee has heard are exactly right.
The Executive always seems to be very interested in involvement on the part of the patient and the public. If we can find a way to allow the patient to have a say in such matters, that is not before time. I do not think that patients have in fact had much say until now, despite your involvement. Many people carry on taking whatever comes when they go to their doctor but then, when they cannot get something, they complain about it.
We have addressed that point about opting out: I think the question was about how health boards are to obtain the capacity in terms of GPs to deliver the services. The other issue, which we also covered in our paper, is whether funding will be available to enable boards to provide those services. Resourcing and funding go hand in hand, and we have concerns about those areas.
I seem to remember that we have been told that some practices simply will not be allowed to opt out. Could you clarify that? What would morale be like in practices that cannot opt out because there is no alternative cover or provision, no matter how things are restructured? I may have understood this wrongly—I see sceptical looks around the table—but I believe that we had evidence to that effect.
There are concerns among GPs that health boards could refuse to let practices opt out because there is not the capacity to cover services otherwise. In urban areas, GP practices can amalgamate on out-of-hours services much more easily; that is very difficult in rural areas. The health boards in rural areas are considering the matter, but there is an awareness that there is not sufficient staff capacity to cover practices opting out. We do not know what the answers are at the moment.
I am conscious that I might have missed Duncan McNeil out earlier.
In your written submission, you state that you
That touches on the issue of equity of service. I accept, as Dr Adamson said earlier, that there may be good reasons why that cannot happen overnight, but if the agenda is about improving services for patients, we cannot take it at face value; it has to be monitored. The best people to judge and assess that are the consumers of the service. If we are going to have equity of service, patients in all parts of the country should have an equal opportunity to have an input, and to make their views known about the performance of GP or primary care services in their areas. That is why we feel strongly that all practices should be part of that review process, if not from day one, then as soon as possible.
How would you implement that? What would be required to take away that minimum practice income guarantee in a year's time? How would you judge that?
The impact of taking away the—
You said that you
We are saying that if there is to be a minimum practice income guarantee, practices should be able to justify why it is paid to them. The performance of the practice, in terms of the services that are provided to patients, should be a key issue. I question why practices might want to opt out of that review. I do not see why they should want to opt out, and I do not see why they should be able to opt out of that process.
It could empower patients if they had a say over the quality of services in GP practices.
Yes.
They could actually affect practices' income. Why do you not support that?
I am not clear what you mean.
Am I wrong? Have I misunderstood? I presume that the minimum practice income guarantee gives a base level. If doctors opt out of quality frameworks, you suggest in paragraph 3.2 of your submission, under "Service Monitoring", that they should not automatically continue to be eligible for the minimum practice income guarantee. What does that mean? I think that that should have been my first question.
We think that all practices should be involved in the monitoring. That is what we are saying. All practices should be involved, and patients should be actively involved in the monitoring process.
I said that there is a problem over the time period because, at the moment, it appears from the notes on the bill that the assessment for quality assurance will be done on numbers of diseases recorded by the practice. That is easy for the practices that have good information technology set-ups, but it is much more difficult for the practices that do not. I was merely flagging up the need for a big capacity-building exercise involving the practices that do not have information and communications technology set-ups that are efficient enough to collect the figures. That is the other reason why we advocate the inclusion of qualitative as well as quantitative assessment, which appears in the explanatory notes.
I seek clarity. Last week, we heard from the BMA that one of the issues was that the incomes of certain practices had to be guaranteed. You say in your submission that those practices that opt out of the quality audit should not automatically be eligible for that MPIG money. The implication is that unless they come up to the standards, they will not get the benefit of the agreement. Is that what you mean? I do not think that it is now, is it? Should they be allowed to opt out? The words are yours.
The point that we are trying to make is that all practices should be involved. Whether it is from day one or within an agreed timetable, we should endeavour to ensure that all practices are subjected to the monitoring regime.
You do not go as far to say that they should be penalised if they do not, but you are raising the issue.
We accept the situation. As Dr Adamson said, there are implementation issues and so on. However, we feel that it should be an objective for all practices to come into the monitoring scheme and that there should be a commitment on the part of practices to do so.
I think that we are as far forward as we are going to get.
We are not going to get there. If GPs walk away from the quality audit, there should not be—
I think that it is an argument of persuasion.
We are not talking about an immediate penalty.
I am not suggesting that there be an immediate penalty.
The issues have potential for the future.
Okay, I give up.
Can we move on? I think that we have dug that seam—
To death.
Your words, not mine, Mr McNeil.
I would like to come back to the issue of balancing the need for out-of-hours care with the new working patterns for doctors, particularly with regard to the ability to opt out of the services. Will that have a beneficial effect on recruitment and retention in the profession?
I agree with what you say about the need to strike a balance. It will take some time after the GPs' working lives have improved before there is an increase in recruitment and retention. There will be considerable problems until that point.
How will the patients perceive the changes? How will the GPs be able to strike the balance that we are talking about? After all, there is no blueprint for this.
That is the difficulty. We support the objectives but accept that it will take time to deliver them. As I said earlier, if the implementation of the contract leads to a chronic shortage of resources, that will be detrimental to patients and will exacerbate the problems with GPs and people's dissatisfaction with the NHS in general. We accept that the resourcing situation cannot be resolved overnight. We would like firm plans to be in place to ensure adequate resources in the long term. If we go down this route without trying to increase capacity in the system—whether through practice nurses, GPs, pharmacists or whatever—we will end up in the same situation in four or five years' time. It is not sufficient simply to provide additional funding for practices. The Executive must take the initiative and consider the longer-term issues of capacity planning and how we are going to get more people into medical school to ensure that we have more doctors, GPs and nurses. Unless there is such a twin-track approach, the GP contract will not resolve the problems that we face—indeed, it could make them worse.
That relates to the question that Janis Hughes asked about how the situation could be improved, because all the improvements depend on the approach that is taken.
In your written evidence, you say that you are concerned that the bill appears to introduce private health care into primary care, as has already happened with dentistry and secondary care. Could you elaborate on that?
Our concern came from a question: what is to stop general practitioners opting out of the contract or NHS provision and setting themselves up as a private organisation that offers its services to the NHS? My concern is that, if there is undercapacity in the NHS, the NHS might have no option but to employ private GP practices as has happened with secondary care. I do not know the likelihood that that scenario will develop, but the possibility was put to us and we are raising it as an issue of concern.
GPs are essentially self-employed professionals who contract their services to the NHS. Are you saying that they would opt out of contracting with the NHS?
Yes. It may be a local issue or what have you, but if a sufficient number of GPs decided that they were unhappy with the contract, for any reason, there is a possibility that they could decide to opt out of it and set themselves up as a private organisation and be available to provide services to the NHS on that basis rather than as part of the NHS contract.
The explanatory notes to the bill state specifically that the health boards would not be allowed to commission GPs privately. However, the problem is with additional services. Let us take immunisation against measles, mumps and rubella as an example. What would happen if all the practices opted out of providing that but there was a private group of GPs who were prepared to do it?
I take your point.
Contracting that private group might be the only way of providing that service.
That is interesting.
I have a final question that arises from the evidence that you have presented and the evidence that we received last week. You quote paragraph 40 of the policy memorandum:
The important thing in all this is to come back to basics and ask what we are trying to achieve, which must be the delivery of better services for patients. It is, therefore, important that we get the bill right.
No doubt, the minister will heed that point when the matter is put to him.
I would like to say that I apologise most sincerely for wasting your time today. I am in way out of my depth.
You have not wasted our time at all.
Could I ask one question, if that is not too impertinent?
Yes.
I would like to ask all the MSPs what their constituents say about the bill.
I do not think that we are here to act on behalf of our constituents.
Do you not get feedback?
We get feedback, but that would be in another capacity. We sit on this committee in a cross-party capacity on behalf of the Parliament to examine legislation. However, we are very interested to hear what you have to say, and I have no doubt that members have been briefed by their constituents and have fed that into their questions in some way. Thank you very much.
Meeting suspended.
On resuming—
I welcome the Minister for Health and Community Care. I thank him for agreeing to hold two evidence sessions with us, the first of which is on the Primary Medical Services (Scotland) Bill.
Two distinct sets of regulations are referred to, some of which are totally within our control. It is a UK contract with Scottish variations, so we have certainly given an undertaking with regard to those that are completely within our control. However, there are obviously other issues with regard to the elements that are being drawn up on a UK basis. We will seek to supply those, but you will understand that they are not under my control in quite the same way.
I understand. Could you prevail upon your colleagues at Westminster to provide those regulations? As there is only one committee here, and no revising chamber, the committee would like the opportunity to look at those regulations as soon as possible.
I do not think that the accreditation standards will be in the primary legislation or in the regulations. I do not have a date for their introduction, but they will not require primary or secondary legislation.
Given that we are talking about accreditation standards, it would be useful for the committee to have that material before we move through the later stages of the legislation.
I am not sure which stage the standards are at. Perhaps Lorna Clark can help.
I think that the issue is being discussed at Scotland level. The accreditation standards will not be introduced until December 2004, when the opt-out provisions will come in. A lot of work is continuing, building on work that professional bodies have done. I do not have a detailed timetable for the accreditation standards, but we can find out more and let you know.
That would be useful to the committee.
I have just a couple of questions on patient needs and balancing those with the need to improve recruitment and retention in the profession. First, do you feel that the correct balance has been struck between patient needs and improving recruitment and retention? I presume that you will say that that balance has been struck, but what do you base that opinion on? I must ask that as a preliminary question.
I am not sure why you set the two areas in opposition to each other. Clearly, the Parliament, in a proxy role for patients and many others, often raises issues of recruitment and retention because the reality is that patients suffer if we have recruitment and retention difficulties either in primary care or in hospitals. The fact that the contract will help to address recruitment and retention issues is very much in the interests of patients, but that is not the only aspect of the contract. I am enthusiastic about the contract because I believe that, in the round, it is in the interests of patients. For the first time ever, funding for primary care will be based on patient need and not on doctor numbers. For the first time, not only in Scotland but in any country in the world, a substantial amount of funding will go into primary care on the basis of quality. In fact, two thirds of the substantial increase that is going into primary care on the back of the contract is for the quality elements of the contract.
I do not suggest for a minute that the needs of patients and the need to have better recruitment and retention are mutually exclusive. However, I think that you would accept, from the earlier evidence that you heard from organisations that represent patients and from members' questions, that there are concerns about the fact that the two areas can be in opposition. A concern that I have raised, not only in this committee but in the Finance Committee, is about the provision of enhanced services, the most controversial of which is probably the out-of-hours service. If practices opt out of that service, it can have a detrimental effect on patients. That is an area in which the needs of the patient can be diametrically opposed to the benefits of recruitment and retention in the profession.
I know that there are concerns, but I am simply saying that I do not accept the point. I would not support the contract if I did not think that it was in the interests of patients. I think that it is strongly in the interests of patients—it is a very good contract for patients.
But what evidence do you have of the number of practices that will opt out of providing enhanced services? If you do not have the figures, how can you give that guarantee?
We have to get our language straight. Out-of-hours services are different from enhanced services. We should be thinking about the enhanced services.
I am talking about both enhanced and out-of-hours services. The latter is included.
Enhanced services are not an opting-out issue; they are services that boards will provide; they will be directed to provide some of those services, while local discretion will apply to other services. That is where some of the big shifts and redesigns will take place.
I am aware of that.
Out-of-hours services are different from enhanced services. They will have to be provided. I talk to a lot of GPs and find that I get mixed reactions from them. What Dr Love said last week might be a quite typical response. He said that GPs might opt out of responsibility for out-of-hours services, but they might not necessarily opt out of the provision of those services.
I am aware of what additional services, enhanced services and out-of-hours services are, but I do not think that you have answered the question. I asked whether you knew the number of practices that would opt out of providing enhanced services or out-of-hours services. Unless you know that, how can you guarantee that patients will not receive a lesser service?
There is an issue, not about opting out of enhanced services, but about opting out of out-of-hours services. The nature of things means that it is impossible to know at this stage how many practices will opt out, but the patient services guarantee is there irrespective of how many GPs opt out of the out-of-hours service. There is a duty on boards to provide that service. If alternatives cannot be provided in certain parts of Scotland, the GPs will not be able to opt out. That is the final guarantee of the patient services guarantee and it is central to the contract.
I have another question on a different matter, but the convener might have a supplementary.
I do. In your letter, you said that
I do not have a specific date for that, but Hugh Whyte might have one.
We expect that the group will be able to issue some interim guidance by the end of October. It will go on to develop models of alternative provision, which should be ready for the transfer of responsibility by the end of 2004.
Please bear with me—I am just checking where that fits in to our consideration of the bill. The stage 1 debate will be on 28 October. Will we be in a position to have the group's report made public by then?
The group expects its initial guidance to be out prior to the end of October.
Will that be available in public?
Yes.
Jean Turner, David Davidson and Janis Hughes want to pursue the same line.
At the moment, doctors in general practice sometimes pay themselves to provide out-of-hours services—they make extra money that way. That happens with Glasgow emergency medical services. People in small practices, as I was, pay themselves to provide out-of-hours services. I did most of my on-call work myself, from 7 in the morning until 6 in the evening. Very little of my out-of-hours work was provided by another service.
The general point that you make is interesting and important. The pattern of service delivery will be different under the contract.
What is your view on Dr David Love's claim that the number of GPs is going into meltdown?
It was interesting to read Dr Love's evidence and then the newspaper reports. The context of his evidence was that, although there was a problem in general practice, the contract addressed it. However, I have read Dr Love's evidence and I accept his comment that there are problems. I recognise that in health, as in other areas, there are problems. That said, as Dr Love pointed out, the purpose of the contract is to address those problems through increased funding for primary care.
I think that we are being slightly sceptical if we test the bill simply on the issue of capacity. After all, we could say much the same for the health service as a whole: we need more doctors, nurses and so on. We need to explore whether what might come out of the bill—the development of specialities, a potential increase in private work and reduced hours—represents a good deal for patients on the ground. Will it give us a situation that is similar to that in acute services, which have received massive resources but are not working out on the ground? Knowing what you know about what is happening in acute services, minister, how will you prevent the same thing happening in general practice?
It is hard to justify a particular situation. Indeed, as far as recruitment and retention are concerned, it is hard to justify continuing to force GPs to work ridiculously long hours. We must address the issue in relation not only to doctors' welfare—and I know that the committee expressed concerns last week about GPs' working hours—but, more important, to the welfare of patients. As with the hospital sector, the issue involves not only some increase in capacity, but the redesign of care. We have to develop those two aspects simultaneously in order to deal with problems with working times.
What about the specific example of specialties? At the moment, a patient can receive a general view from a practitioner. Can we look forward to a situation such as that in acute services, where we would have to see three doctors before we actually received treatment?
I make it clear that all practices have to provide the essential services. The expectation is that the vast majority will provide the additional services as well. The bottom line is that practices cannot opt out of essential services in the interest of specialism. However, within those parameters, many would see a lot of sense in certain GPs developing certain specialisms, along with their provision of general services, because that too supports the objective of delivering as much care as possible within primary care. That would only, of course, apply to services that are safe, and that make people feel safe. The underlying principle of all service change is that it must be based on services that are, and that make people feel, safe.
That is why we require sight of the regulations.
I will take you back to an answer that you gave Kate Maclean earlier. You made reference to the patients guarantee. They way in which you phrased your reply seemed to suggest that patients would not see any diminution of services that they could access because of the guarantee. The next stage is that, if there is a problem, health boards will fill any gap. Then you went on to say that, if they cannot fill the gap, it is back to the GPs, who will not be able to reduce or withdraw from services.
There are definitions of additional and enhanced services. Some of those are covered in my letter, and more can be given if you wish.
I am sorry, but I must press you on enhanced services. We really are in the dark. In your letter, you quote a paragraph from "Investing in General Practice", which allegedly defines enhanced services. However, it does not actually define them: it gives examples of what they might be. Our understanding is that enhanced services are things such as the provision of contraception services—no, that is an additional service. Can we define specifically what an additional service is and what an enhanced service is?
We can certainly spell out the additional services. There are lists of enhanced services, which I can read out, if you like.
We accept that; we have a copy of the contract. We are interested in the enhanced services.
We do not want to put a lid on the enhanced services. We have lists, but the possibility of including other services is in the nature of redesigning care. The mechanism is good. People have struggled for years with the question of having a financial mechanism that supports new services in primary care, because a legitimate complaint from GPs sometimes is that they are asked to do more, but not given the resources for that. The enhanced part of the contract is a financial mechanism, so that if more services are delivered in primary care, the resources follow to deliver them.
Will you give examples?
The list in the general medical services contract includes flu immunisations; preparation of records for quality; childhood immunisations; more advanced minor surgery—the more simple minor surgery comes under additional services; anticoagulant monitoring; intrapartum care; and drug and alcohol misuse services. Lists exist, but my point is that they cannot be closed lists, because the nature of enhanced services is that, over time, there might be still more that can be done in primary care.
If I have to go somewhere other than the GP practice that I currently attend for those services, is that not a diminution of the service that is provided to me?
I am not sure whether you would be able to receive all those services from your GP. Minor surgery is a good example—I would be surprised if that were available from your GP. Contraceptive services are one of the additional services, which might catch people's eye, but it is interesting that that is not part of the general medical services contract. It is not as if you have all those services and you are losing them. You are more likely to have more services in primary care as a result of the contract, rather than less.
That is what we need to know.
Does Kate Maclean have another question, or will we move on to Mike Rumbles's question on rural practices?
I have another question that arose from the Finance Committee. Do you want me to ask that now? It is up to you.
We will leave that now and move on to Mike Rumbles's question, after which we will return to your question.
I have two questions, one of which is on rural practices. I am concerned about the minister's evidence that the Parliament is the proxy for the patient. It strikes me from the evidence that the patient has been forgotten somewhere and that the Parliament is a backstop. As you heard explained to the committee, paragraph 40 of the Executive's policy memorandum on the bill says:
I repeat my point and extend it to say that politicians in general—including ministers—are, at their best, the proxy for the patient. That is the justification for our involvement in health. I accept that my operations as a politician will not intrude on some clinical matters, but I agree that that is sometimes a grey area. I listen closely to clinicians' advice on clinical matters; it is reasonable and correct to do that. However, I agree with your general point.
I am delighted to hear that commitment from the minister, which has certainly answered my second point. I wish, however, to pursue the minister about what he said in relation to my first point. I will outline the problem in a nutshell. We are being asked to examine a bill that, on many pages, says that regulations will do this or that. The first bill that I had to deal with in detail was the National Parks (Scotland) Bill, which, like the Primary Medical Services (Scotland) Bill, was an enabling bill, setting the framework for regulations to come in later.
That is my clear intention, as I spelled out in my letter. The only caveat that I mention, in the interests of realism, is the UK dimension to some of the regulations. We will press to get all of them done by stage 2 but, because of that UK dimension, it is right for me to advise you that it is not entirely within my control.
However the regulations turn out, much depends on the fact that the people have to be there to provide the services. I am concerned that, for every 100 general practitioners working under current arrangements, 150 replacements will be required. If the people are not there to relieve the doctors—I am thinking of island communities in particular—then how can the regulations be drawn up in such a way that the new contract will draw people into the service? I find it difficult to see how it will do that if people do not know the number of experienced doctors and nurses that there will be. As we know, it takes a long time for people to gain the necessary experience to work in remote areas. It scares me a little that we do not know the relevant numbers, never mind the regulations.
I am not sure about the basis of the BMA's figures, but of course I accept that we need to expand not only the medical work force, but other parts of the health service work force too, which is why those are key commitments in the partnership agreement. We know more about work force planning than we did three or four years ago, but we still have much work to do to catch up in an area of the health service that did not feature at all in the past. I fully accept that we must do more GP work force planning, but I hope that what I have said about training numbers in the meantime will reassure people, given concerns that have recently been expressed.
I want to move on. Helen Eadie has a question.
There may be disquiet about patients, but there is also disquiet in the committee about the size of the GP response in the ballot. I believe that 70 per cent of those who were able to respond did so and that only 79.4 per cent of those voted in favour of the contract. With such a response rate, it would appear that only 56 per cent of those who were eligible to vote voted in support of the contract. What do you think about those figures?
Members do not want comments about Scottish parliamentary elections to be thrown in as a smokescreen, minister.
That is the most salient comment to make because—
I have just come back from Sweden, where there was an 84 per cent response rate in elections.
Ballots of any kind will give rise to the obvious comment that Christine Grahame pre-empted my making.
This discussion is about the contract and other serious matters.
We will leave electorates out of things. The reality is that by the normal standards of trade union ballots, for example, that would be a high turn out and level of support for a proposal.
Given that the matter relates so closely to GPs' pay packets, the results are surprising. Does the ballot represent some unease on the part of GPs? Do they not understand the issues that are involved?
The same remarks can apply to the general public. Unease and concern can result from a total comprehension of issues, but it is not insulting to anybody if we recognise that there is also unease that is perhaps based on misunderstanding. In respect of the contract, such unease might be the result of people's not keeping up with all the developments. For example, the MPIG was quite a late part of the contract. Different views about the MPIG have been expressed this afternoon.
We have heard concerns that many of the proposals will be implemented by regulation. Given that, as the minister acknowledges, many GPs are not fully au fait with the proposals, is there not a danger that when GPs become aware of the exact details in the regulations, a significant number of them will not be taken with the process?
The member will have heard last week the generally positive comments of the BMA and the Royal College of General Practitioners about the contract. It is difficult to speak about GPs in general because they have different views and they will want to see the regulations, which is understandable. However, the organisations that represent GPs are positive about the contract and, although it is not possible to speak for all GPs, the ballot suggests that the majority of GPs are positive about it.
We have exhausted that subject for the time being.
I ask this question with the benefit of hindsight that I have gained through dealing with legislation in the previous committee. Given that the bill is unique because it is underpinned by a contract, do you expect Executive amendments to the bill?
The bill might be a little unusual. At the moment, I do not envisage any Executive amendments, although my colleagues will correct me if they have something up their sleeves.
That is on the record.
My colleague has just told me that there might be some technical amendments.
That caveat has been stitched in for you, minister.
A minute ago, the minister said that the Scottish contract is different. I was going to ask whether we have the right balance between local and national needs, but I would like to know whether the minister feels that the contract deals with the geographical and demographic situations in Scotland, which are different from those in the rest of the UK. That is particularly true in rural areas, where the average age of the population is rising even faster than in other parts of the country.
I feel that we have got the balance right in achieving a UK contract with Scottish variations. The distribution formula was one of the points about which we were most concerned and we think that we have achieved a formula that suits Scotland's needs better than the English formula would have done.
As you know, I agree with you about the cutting of regulation, but do you think that you have carried the rural and remote practitioners with you? That seems to be where the great body of unease is sitting at the moment.
I think so. The situation has moved quite quickly. Some, although not all, of the unease is due to the fact that the MPIG arrangements came late in the day, as did some of the agreements around the Scottish formula.
I lodged a written question some time ago to which I have not received a reply. To save you some time in answering it, I will ask a throwaway question. Do you intend to meet rural practitioners to discuss their fears?
I am always delighted to meet clinicians.
I will take that as a yes, minister.
I met several rural practitioners over the summer and I will be pleased to meet more.
Having considered the financial memorandum, the Finance Committee raised a query about the fact that the funding mechanisms for practices may now have a consequence for other budget areas that are not covered by the memorandum. In other words, it seems that there might be a change in who is delivering what and how that will be funded. There is a concern that that will result in some GPs pushing more and more into acute services and leaving other parts of the service to pick up the slack under the new working arrangements. That concern seems to have arisen as a result of inadequate clarity in the financial memorandum. Could you comment on the matter?
As part of our distinctive approach to health in Scotland, we are trying to break down the barriers between primary and secondary care. That could work in several ways. My general take on the contract is that a lot of the movement will be in the opposite direction. For example, you could say that the enhanced services part, the quality payments that are promoting chronic disease management and other forms of service in primary care are rewarding people for shifting work into primary care. However, I suppose that you could also say that one quality outcome might be more referrals in certain cases to secondary care. I suppose that that would be possible.
Do you agree that funding will follow the treatment and the patient rather than being hidebound in fixed budgets?
The health budget and the Scottish budget and so on are all fixed at a macro level and the issue is the directing of resources to the right places. I do not have in my head the precise words that the Finance Committee uses, so I am not entirely clear what it had in mind, but I do not envisage that there will be a major shift from primary to secondary care as a result of the contract. If there were to be a shift, I would expect it to be in the other direction, which is, of course, the intention and direction of policy in other areas as well.
As a result of the evidence that the Finance Committee heard, there was some concern that linking funding to quality targets might cause a problem if elements of the targets are outwith the practices' control. I think that the Finance Committee questioned whether linking to targets was the best way to allocate funding and wondered whether account would be taken of difficulties arising from that in certain cases.
In general, the tying of money to quality outcomes is new, not only in Scotland but throughout the world. It is an exciting development and something that I would promote. In relation to the contract, two thirds of the additional investment in the next three years is tied to quality outcomes. I am sure that patients will welcome that.
I do not want an answer about MMR. The question was not meant to be negative. I was voicing the concern of the Finance Committee, in which the question was raised—it might have come from a witness who represented GPs. Let us forget about MMR and imagine that a target cannot be met, for a reason that is outwith the practice's control. Would that be taken account of in the funding?
There is some allowance for exception reporting in relation to other issues, but most of the controversy concerns immunisation.
All the quality and outcomes framework clinical areas are subject to a degree of exception reporting, which takes into account the fact that some patients react badly to drugs or cannot tolerate maximum doses. Therefore, one cannot always achieve evidence-based practice. Practices will be allowed to have those patients accounted for in the level of achievement. One of the matters to be taken into account is informed dissent or informed non-consent.
That concludes this evidence session. I thank Dr Whtye and Ms Clark. The minister will remain for the next session.
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