I welcome Professor Sir John Temple, chair of the short-life working group on securing future practice: shaping the new medical work force for Scotland; and Dr Robin Cairncross, senior medical officer in the Scottish Executive Health Department. I refer members to paper HC/S2/04/19/2.
Are you satisfied with the progress that has been made by the Executive to date in working towards the recommendations of your 2002 report, "Future Practice: A Review of the Scottish Medical Workforce"?
Shaping the New Medical Workforce for Scotland): I thank the committee for this opportunity. "Future Practice" was accepted virtually in full by the Executive when it came out. The on-going work from that was part of the reason why the short-life working group, which I chaired, was set up. The first group was not an Executive working group; it was my own working group, which I convened. We took a year and a bit to accrue all our opinion—much of it was indeed opinion rather than evidence—which we put into the form of a report. That was accepted by the Executive. Now is the time when I would expect the Executive to start to take forward the recommendations that we made. I am not sure that the Executive had much opportunity to do so before, as further work was required to clarify some issues.
I understand what you are saying about timescales and about the other work that was required. Are there any areas where you feel more progress could have been made by now?
I am not sure that I am qualified to say that, as I am not a member of the Executive. Whatever needs to happen now needs to start happening quite quickly. We have given what I hope are clear messages and recommendations. I hope that we have posted the necessary traffic lights to say what needs to happen in Scotland for health care delivery. It is up to the Executive to make the right decisions to take that forward. That will not be resource negative, of course.
So you are saying that we are starting the process of determining where the priorities should be.
We have laid the priorities out. Our second report sets the scene carefully and clearly—at least I believe it does. We went back and considered the fundamentals for health care delivery in Scotland against the background of ill health in Scotland. It is clear from my accent that I am not originally from Scotland, but I spent three years here. I learned an awful lot about the health care system in Scotland, and I could compare issues here to those that arise south of the border. There is no doubt that there are some real challenges here in relation to the health of the nation. Once we have accepted those, we need to examine the health care system.
Does it concern you that changes are happening piecemeal and at a local level, without any reference to the bigger picture and the national plan for where we want health care services to be delivered?
That is something that I feel strongly about, and I have said so. To deliver these sorts of changes, one needs a macro system that can look down from the top and say what needs to happen, and it needs to have a big enough critical mass to allow that. I do not think that that can be delivered when there are 13 or 15 bodies pitching in the same pool. I compare that, because I must, with the situation down south: England has 30 strategic health authorities for 60 million people, whereas Scotland has 15 health boards for 5 million people. That demonstrates two fundamentally different ways of approaching the problem. Of course, not everything has to be top down, but in my view the initial strategy has to come from the top down because one has to have a big enough macro-economy to be able to do something about changing it. That is why we say quite clearly that health care planning and delivery need to be co-ordinated into much bigger units. Of course, that is a huge problem, because people have just got into the present system after a lot of change and upset and if we say that they will have to change again that will bring a huge reaction, but I believe that that is what needs to happen. The message is: 30 strategic health authorities for 60 million people versus 15 boards for 5 million people—that says it all.
Before I bring in Duncan McNeil, does Dr Cairncross want to respond?
Thank you. I am fine at the moment.
On the same theme, the 10 key messages that you laid out in the 2002 review stressed the need for public involvement. At the end of the 10 key points, you stated:
We have not achieved the recommendations yet. From reading the popular press, which is one way to judge public involvement and knowledge, I perceive that there is a heightened awareness of some of the issues, but we have to go further than that. The political willingness to take the matter forward is equally important—that is why we included it in the report. In fairness, I must say that when I presented the report to the minister, it was as a result of that willingness that he allowed me to go on and do the second review, which considers certain issues in much more detail. There was a genuine realisation that political involvement and complicity is essential. In the past, the problem in so many places has been that because we cannot get professional, public and political consensus we go nowhere. We need all three for change to take place—that is not easy, but it has to happen.
You felt the need to make the same recommendations in the 2004 report.
Of course.
Have we achieved the level of public and professional debate that is necessary to allow a realistic look at the challenges? Do we need a national debate?
Yes. There has been quite a lot of local debate, and in the intervening period several further reviews have been carried out and inquiries have been set up on the same issue. You must have noticed, as I have, that the same messages recur regularly. A national debate would be another approach, but I am not politically astute to the level of knowing how that would be undertaken.
You agree that how the message is being carried does no favours to the people who oppose cuts in their localities and drowns out the voice of professionals and people like you, who are trying to manage expectations about future health services.
I agree that we do not yet have the right forum to put the message across properly to the public.
I want you to clarify a point that you made a moment ago. You said that bigger units were needed. Do you mean bigger planning units, health authority units or hospital centres for delivery?
I probably mean all three. We must start with strategic planning and the organisation and implementation of service delivery. My view and my group's view, this time and previously, has been that that needs to be organised on a larger scale than at present. There are several ways to do that. Number one is through arranging liaison between existing health boards, but that would have to be real liaison through which people gave and took and did not plant territorial flags and hang on. However, when we go beyond that, we need service redesign, as the second report says. Both my reports were about medicine, but that is not to the exclusion of the rest of health care. [Interruption.]
I am sorry to interrupt you, but the noise had started again. We will deal with it and continue for now, but if it starts again, we will have to settle it, because the situation cannot continue.
My reports dealt with medical care because that was the subject of their specific remit. I deliberately kept them focused on medicine, because that was our brief. However, that is not to the exclusion of the rest of the health-care provision system. The parts must work together, because the system is multifactorial.
You said that we do not have enough clinicians, consultants, general practitioners, doctors and house registrars, but according to statistics from the Scottish Executive, 10,000 extra people have entered the system since 1993. I know that the European Union working time directive causes pressures, but I have difficulty in understanding why we continue not to have enough people.
If I may answer that—[Interruption.]
Excuse me—I am sorry to interrupt again. Do members feel that I should suspend the meeting briefly to deal with the noise?
It is not bothering me.
You want to continue. Is it not bothering you?
No.
So it is just me who is becoming very angry. [Interruption.]
As long as it is not something that I have done, I do not mind.
I am sorry. Please proceed.
Where were we? We can ask whether, 10 years ago or now—let us take now—we have enough doctors and nurses and enough of everybody else to run the health care that we deserve. The answer is no. It is clear that Scotland is slightly better off than any other UK country, but it is still below the average for most of Europe.
Is that a short-term or a long-term problem?
It has been and remains a long-term problem, for a raft of socioeconomic reasons.
Short-term or long-term problems?
They are all predominantly medium to long-term problems.
I would rather that questions were asked through the chair, because I have a list of people who want to ask questions and I want them to have a chance to do so.
Professor Temple, you talked about structures and strategic overviews and you more or less laid out a plan for the amalgamation of health boards into regional strategic authorities. However, the concerns that we are currently hearing from the public are less about how the system is organised than about how long it takes to access that system in an emergency—in other words, taking medicine to the people. I would like to hear your views on that. Schemes were tried in which consultants were sent to cottage and community hospitals, to take clinics closer to patients, but that approach seems to have been abandoned, partly because of the lack of bodies on the park, which means that people cannot afford the travel time if the patch is to be properly covered. How can a balance be struck between the structural overview—the accountants' guide to the best management of hard facilities—and the fact that although the public has bought into the idea that they might have to travel further for specialised care, as you mentioned, they want immediate problems to be dealt with in their locality? How does that fit with your model?
It does fit in with the model, but we must carefully consider the two different issues that you raise: emergency provision; and the more elective, planned process of provision. The latter is relatively easy, because most people understand—if it is properly explained to them—that in the case of a major or once-in-a-lifetime event, it is better to go where the best care can be delivered. That might mean that people have to travel for specific care and come back to access step-down facilities, but if the process is explained and care is taken the public can be won over on that issue.
Thank you. That is quite clear.
There are many things going through my head. My first thought is that when we plan ahead, we must take account not just of the illnesses that are suffered now, but also of those that are coming people's way. We have an aging population with multisystem problems. A large number of people have smoking-related diseases and even if we banned smoking tomorrow, all the diseases associated with smoking, as well as those to do with obesity, would still come our way. Our capacity is diminishing; as well as having half the number of beds that we had in the mid-1970s, we have fewer people to treat patients, as Professor Temple said.
In fairness, much of that will happen if and when we get more people on the ground, because that will provide greater opportunity for devoting attention to such issues. It will also allow us to expand community services. Many of the things that Dr Turner has just mentioned ought to be dealt with at community level. I am not an expert on community services—I am a general surgeon; that is where I come from—but such work is increasingly being carried out by community services. However, at the moment we just do not have enough people. That is why Sir Kenneth Calman's report, which is complementary to mine, talks about increasing the number of medical students. We highlighted that in 2002. That is good, because it means that we will get more graduates in Scotland and that we will have a chance of retaining more doctors. That will start us on the right path.
You said that certain problems strike you as being more prevalent here than they are elsewhere in the UK. Smoking was one of them; what are the others?
Obesity is also a big problem in certain parts of Scotland. We see from the papers that it is a huge problem throughout the UK, but the problems are particularly striking here.
I have a couple of questions. First, how confident are you in the robustness of the available evidence on morbidity and mortality rates in relation to the trade-off between access and specialism? What effect does the trade-off of moving from local services to specialisation and centralisation have on morbidity and mortality rates? How confident are you about the evidence that the trade-off is worth it in terms of morbidity and mortality?
I said that.
Have you calculated how many workers would be necessary to avoid the trade-offs that are being made?
Let us deal with the trade-off between keeping everything as it is and trying to change it—that is what we are really saying.
I am not saying that we should keep everything as it is. I am asking what staff numbers would be necessary to maintain or improve services.
To maintain the present services and comply with the working time directive and the work-life patterns that young people now expect, we would need an awful lot more people on the ground than we have now. In many localities, if we put an awful lot more people on the ground, they would not have much to do for a lot of the time—they would just be sitting around waiting for emergencies. Therefore, the trade-off is acceptable.
Have you worked that out statistically?
I have not, but we provided some statistics in the 2002 report, "Future Practice: A Review of the Scottish Medical Workforce". There are units in the Executive that would give you chapter and verse on what that means.
Have you calculated the number of workers that would be necessary?
We now need a minimum of five and probably eight people on any shift at any time to comply with the working time directive. If there are eight people in a locality with a small throughput, they cannot keep their skills up to date and they do not see enough work to keep them interested. A trade-off must be made and the only way to do that is to alter the way in which we deal with the work in that locality. A lot of the work is therefore referred or taken elsewhere if there is an emergency.
I understand those arguments, but they do not answer my question. I am trying to put the issue in a global context to make a political judgment about where we are going. You are making the argument, which we all hear in our areas, about why such change is necessary, but nowhere are we able to get evidence on centralisations that have had a positive impact on morbidity or mortality. I ask you to pitch the numbers that are necessary, so that we can get a handle on the global gap, because the examples that you quote are all locally based, are about particular shifts and about how you cannot get enough consultants and what is not practical. That is an argument; it is not providing a global picture and a global figure.
If I may say so, it is fact as well.
Yes, but it is an argument about why something is necessary, in the context of the status quo. I am coming at the issue from a political perspective, and trying to picture our vision of the NHS if we were not restricted by some of the problems. On the basis of Scotland's health situation, health needs and the geographical and other variations that need to be addressed, what would an NHS that was not restricted by finance or resources look like? How many doctors, nurses and other health professionals would be in that NHS? In order to judge other reports and your submission, it is necessary to understand that, but to my knowledge that kind of work has not been done.
I do not think that there are any factual bases for that argument at present. The work has not been done. However, there is enough evidence to tell you that the status quo cannot continue, therefore if everybody just sits back and waits for the status quo, you will end up with hospitals not being staffed for certain parts of the day, and when people present at the front door nobody will be available to treat them. That is not acceptable to the public or anybody else, and it has to be changed. I am telling you that we have looked at some of the things that might have to be done to change that situation, but I have not said that we will close anything. I want to keep that on the table. Absolute numbers would have to be examined in every locality, but you are not denying, are you, that there is a great shortage of doctors in Scotland?
I am not denying that at all, which is why I am trying to tease out what is necessary. The other question is, where there have been centralisations and measurements have been taken of morbidity and mortality and the effects of centralisation, have health boards' claims about improving safety actually been achieved? I am not aware that they have.
There are examples of centralisation where health care in major disease specialties has improved. We would not want cardiac surgery in six centres in Scotland for 5 million people. We would not want neurosurgery in eight or nine centres, neither would we want that for oesophageal surgery. If you examine resection for cancer of the oesophagus, which is an increasingly common disease in the UK, the results are best in centres that do a lot of that work and worst in centres that deal only with the occasional case. We know that centralising that sort of specialisation definitely works. That is accepted, and that is what happens now. We are talking about extending that further and we are considering in particular some aspects of emergency medicine that cannot be dealt with because we do not have enough people on the ground to deal with them. That is where we are coming from.
It might be helpful to say that as the report was being written, what is in Carolyn Leckie's mind was in a lot of our minds: how do we get the evidence that she is looking for? In Scotland, that evidence did not exist a year or so ago—it was difficult for us. Sir John has set out how we thought through the processes. Since the report, we have entered into a major change, with the Scottish Executive implementing a Scottish national work force strategy. It is a wide and embracing strategy that will encompass the kind of arguments that you want to be thought through, because it will not work unless we can answer some of those questions. That is prospective, if you like. It is a consequence of this work.
I think, sorry—
I would like to move on. I have a list of members who want to ask questions and we have only another quarter of an hour.
We are told that there are a number of drivers of change and that there is a need to reconfigure or centralise services—however you wish to phrase it. Some of those could be understood as relating to longer-term solutions, such as the working time directive, which will be with us for the foreseeable future, but some might be shorter term, such as those related to recruitment and retention issues, particularly in respect of medical staff but also across the board in the health service. You said earlier that there are staff shortages, and the Academy of Medical Royal Colleges says that little progress has been made in medical recruitment and retention. What are the reasons for the shortages that are leading to the need for reconfiguration? Why is nothing in place to address that and what do you think should be in place?
I need to think carefully about that for a minute.
You mentioned the difference between specialties. I accept that some specialties are perhaps more popular than are others. Those of us who visited the Western Isles as part of our initial investigation found that one of the problems there was the need for generalists. There has, in today's medicine, been a move away from general practice to specialties. As you said earlier, one size does not fit all and every locality has different needs. Obviously, localities such as the Western Isles have a need for generalist physicians. What can we do to attract more people to do that, bearing in mind the clinical need to update skills and so on?
I looked into that two years ago, three years ago and even five years ago. There is almost a separate problem, which is that there are some great attractions to going to work in such areas, but to work there one does—whoever one is—need to be very much a generalist, because one might be faced with a variety of issues that one would be expected to deal with, certainly in the first instance. One of the difficulties of the present system is that it tends to train people who become increasingly specialised the further on they go, which increasingly takes them away from being generalised.
What is the practice in countries that have similar topography to Scotland, for example the Scandinavian countries? How do they resolve the problem of delivering services to rural and remote areas?
Scandinavia has similar problems, but it has a slightly different lifestyle approach to them, in that it is quite in order for people to want to go back to such areas to live and work. Australia has the same issue as we do with its outback—it is now running into real recruiting difficulties for services there.
I have two points to add. First, on recruitment and retention of staff in Scotland, the complementary report by Sir Kenneth Calman—which the committee may not have seen—about basic medical education, identified the need to increase the number of Scots who enter our medical schools. The number is low, yet we understand that a Scotland-domiciled entrant is more than twice as likely to remain and work in Scotland as one who is not. There is therefore a yield from getting more Scots in. The policy is not meant to be in any way discriminatory; it merely recognises that the balance is too low at the moment and that we would like more Scots in our medical schools.
On the business of there being too few Scots entering medical schools, how is that reflected in applications, and in applications that are successful? Are we making it too difficult for people to get in? It is anecdotal that one must have only A grades to get into medical school, but that does not mean that we will get the best doctors at the end of the course.
There are many anecdotes about that and we have yet to sort it out, but most medical schools are, in effect, prisoners of the profiles of their applicants at the moment. In Scotland, we get many applicants from south of the border. Scots, even with that disadvantage ratio, have a better selection level than non-Scots, but it is nowhere near enough. As to whether they are being asked to perform at a higher level, there are different views on that. That is an area that we will want to look at carefully in the near future.
I might ask the General Medical Council about that as well.
It seems to have been a long time since Sir John said this, but I drag you back to your comments about people's experience of a major event and what services should be delivered locally. My perception is that you have won the argument about the major event—people are used to going into the major cities to receive treatment for a head injury and for cancer services and heart services. However, we have no agreement on what happens in communities and emergency services. I am concerned about the idea that one cannot go along to their local hospital with wee Johnny or wee Josephine to get their broken arm fixed, but instead have to travel for that treatment. We are a mile away from allowing that to happen.
That is a fair criticism of my profession at present. The profession has to change its views on the matter simply because of the way in which contracts are working out. I keep returning to the working time directive from which we cannot get away—it is mandated and it has to be observed.
Earlier, Carolyn Leckie talked about large hospitals and outcomes. I have been led to believe that the centre for health economics in the University of York undertook in 1997 the most comprehensive study of the relationship between, on one hand, hospital size and the number of patients treated and, on the other, clinical outcomes. I do not want to have to read the relevant paragraph out, but, basically, the study did not prove one way or the other whether bigger centres had better outcomes.
Those are well illustrated points, Dr Turner. The view that you are expressing is that change is being driven by necessity—in terms of staffing and costs and the boards' overdrafts—rather than the needs of the patients.
I have no detailed knowledge of the situations that Dr Turner raises but it seems that she is describing a piecemeal process of change that is driven by a necessity and which is not directly related to patient safety.
That is why people are worried about the changes. It is very difficult to carry the public with you when the people who receive the treatments are saying that things are not better. Hospitals are being closed to shove units into a different place—they are just being transferred from here to there—and people do not have easier access but are receiving a worse service. Lives may well be put at risk—I do not need to describe the details, but I have mentioned a few things—and that is extremely worrying. There are also implications for the recruitment of staff in medicine. If health professionals have built up systems to be the best but they are broken down, torn apart and thrown away, that tears the heart out of them. It also means that the health professionals cannot maintain their professional standards. Their professionalism is being compromised to the extent that they ask, "Why should I stay here?" It is all tied up together.
Of course it is. A lot of change used to happen because we were chronically under-resourced. We are now constantly reassured that the amount of resource that is going into health—throughout the UK, not just in Scotland—is increasing exponentially. This may be a totally naive statement, but that should mean that, when we introduce changes now, the purely financial aspect is not the overriding factor as it often has been in the past. That is the advantage of having much more from indirect taxation going into health, and we should see the benefits of that.
I want to move on, as I am conscious of the time. We have a final list of questions.
I would like to pick up on something that Sir John just said about investment. We all acknowledge the fact that there has been increased investment in the health service, all of which is very welcome. The problem is that it is very hard to see how the patient benefits from that investment. If a patient or another member of the public sees their local health services contract while record levels of investment are going to the health service, they experience a quandary. Also, when health boards are strapped for cash because the bulk of the money has gone into consultant contracts, GP contracts, drugs budgets and so on, the patients and the public do not see a huge benefit or the revolutionary transformation of their health service.
You raised a lot of issues. In the report, we move towards a more generalist type of training. We define the types of doctor that we need and suggest that only a small number need to go to that much higher—or deeper—level of specialisation. I agree that at present we train everyone to the highest level before they finish their training programme in hospital practice and many people never need to use all those additional skills. We are suggesting ways in which we can change that across the whole country.
What incentives do we need to use to get people to go into that more general medicine? You said earlier that it is not an attractive proposition.
I think that it will become attractive. The job will still be fulfilling, exciting and challenging. It will map more realistically what the doctors do. We will just not give them all the extra depth of training that they do not need. That will get doctors out and earning their consultant salaries earlier.
My question is really a follow on because Shona Robison asked the first part of the question that I was going to ask.
We have made that suggestion, to an extent, in our views on what we might do about recruitment in some of our remote and rural hospitals. Some of those hospitals are unsustainable under the working time directive given the staff numbers that they have.
Mine is not a remote or rural area. I live in a semi-urban and urban area.
In some of the semi-urban to urban areas we have suggested that there could be some linkage. Certainly, if there are two hospitals in a locality and we decide that we have to combine the functions and pool the staff of hospital X with those of hospital Y, which is of a completely different size, the staff will have to work at both units. That is quite a painful process, but it has happened and is what we need to do. There are some good examples of areas in which we might want to do that.
A concern about the modernising medical careers programme, which you hinted at, is the public perception that fast tracking people to become consultants might not give them enough skill and might not maintain standards. Will fast tracking dilute the role, which again equals patient risk? How do you answer those queries?
The answer to your question about whether the role will be diluted is no. We fast track people because we do not include the significant periods spent marking time while waiting for the next jump, which are currently built in. There is no reason on earth why we have to have the longest training programmes in the western world, but that is what we have at present.
You feel that those people are perfectly capable of running consultant teams, which brings in various other skills within medicine.
I am absolutely sure that they can do that. They do not all jump at consultant jobs when they finish, but that is for a different reason: they still try to cherry pick the job that they want. Young people use all sorts of holding strategies to hang on until they see the sort of job that they want, but they are perfectly adequately skilled. They go through a training programme that ends with their completion of specialist training. We sign documents to say that they have completed the programme and that they are competent at that level to go out into the big wide world.
Do you agree that they are not competent to provide training? They have to go over some more hurdles if they want to develop and train registrars.
I do not quite understand your question. What I am saying is that when someone gets their certificate of competence that means that they are competent at that level. We define the levels as where we think they should be. There are only two levels of trained doctor. The first is the judgment-safe level, which will cover the majority who will run district general hospitals and so on. A smaller number require in-depth care skills beyond the first level: I am thinking of people who will do oesophageal surgery, for example. They will get additional competencies for such skills, but when they get their certificate, wherever they are, they are competent and confident.
Do you think that that will attract young graduates from other parts of the UK to come here and go through that fast-track training? Could Scotland develop that competitive edge over the rest of the UK?
Although the approach will start in Scotland, it will be universal before very long. We are not promulgating the programme just for Scotland; it is something that has been discussed by various bodies in other parts of the UK. Because of the size and scale of the service here, we have the opportunity to get things moving fairly quickly. That is a plus; it is a wagon that we should try to jump on.
People had the perception that your reports have become the justification for centralisation, and they have certainly been used to justify some of the discussions that we have had, but you have dispelled that a bit today. You are arguing for centralisation of services where it can be clinically proven to improve outcomes, patients' experience and equality. We have listened to that argument. We have heard that you would support a national debate. We have heard that the number of boards in Scotland is perhaps too high, and we should perhaps be looking into that. Do you have any more thoughts on how the committee inquiry could further inform the work force planning agenda? I am sure that others will have more thoughts on what you have said today.
If we could move those arguments forward, we would probably get some real progress. I said three and a half years ago—I am still saying it now—that Scotland could start to take the sort of action that Ireland is taking on smoking. That is a big jump but, although a smoking ban will not have an immediate effect, if we started to act now, the next generation to sit round this committee table would see an effect. We need to influence young people. To me, that is the numero uno priority for health prevention in the UK, and particularly in Scotland.
You will be aware that the committee is considering a member's bill on smoking on which we will shortly produce a report.
I was not aware of that, but it is good news.
We will produce a report based on the evidence that we have taken, some of which has come from Ireland and New York.
I welcome Professor David Kerr, chair of the advisory group on the national framework for service change, and Derek Feeley, head of national planning in the Scottish Executive Health Department. I know that you were sitting through the previous evidence session. Could you update the committee on the work of the advisory group and on any progress that it has made to date?
Our group has been asked to provide a vision for how the health service and health care delivery will evolve over the next two decades in Scotland, so its work is forward looking.
On your website, you say:
Clearly, this meeting is a good chance for us to establish contact with each other. The possibility of coming back here, at your behest, would be reasonable, sensible and logical. We would also be interested in catching up with things with individual members. There are a number of clear hot spots, or areas of controversy, to do with service delivery, and I would like to find out more. If we could engage with committee members, using you as a conduit into local communities so that we could further the debate, that would be enormously useful to us. We can ensure that you are kept informed of our reports and of what steps we are taking.
I was thinking not only of MSPs in the committee but of MSPs across the Parliament. I am not quite sure how we will move forward, but your suggestion is interesting.
We are trying to work in an open and transparent way. The minutes of advisory group meetings go on the website as soon as the minutes are agreed. The minutes of all the work streams are also on the website.
Can you give me some idea of the timescale?
A draft of that paper will go to the advisory group meeting on 4 October, so some time later in October would be ideal.
We will bear that in mind.
It is a good offer, and our briefing papers today have been useful. I want to go back to some questions that were put to Professor Sir John Temple and to his recommendations on involving professionals, politicians and the public. Our papers tell us that, since 1998, the professions have dealt with the issues one way or the other, but almost exclusively in dialogue among themselves. I am delighted that you are making this offer now, but I am tempted to say that, in some cases, it is a bit late. However, I do not want to spurn your offer, which I think is genuine. There are certainly people in my community—among the professionals and the public—who would wish to talk to you about the Argyll and Clyde review, and I would welcome that.
The offer was well meant and true. When you say "a bit late", you do not mean us really, because I have only been here for about two minutes, not since 1998.
No—I do not mean you personally. I am talking about professionals having a dialogue with other professionals about the health services delivered to our people, to whom you and I are accountable.
Your question to John was apposite and interesting, and clinical engagement is awfully important. That might be why Malcolm Chisholm got a doc to lead that engagement. Not only do we have to engage in a dialectic with the citizens of Scotland, but we have to engage—as John clearly said—with drivers for change, and so on. If we are considering service redesign, the slogan would be "Work better, not harder." We need to be able to engage with the professions, and sometimes that means doc talking to doc, but that must not be exclusive. We must open out and get that dialectic going with the public.
I was interested to hear you say that you would like to use this opportunity as a conduit into local communities. What strikes me is that your remit says that you do not intend to override or delay current service redesigns in the NHS but that you intend your work to complement future planning by boards. In the communities that I represent in south Glasgow, a lot of the changes will have taken place or will be on the point of taking place by the time you report in the early part of 2005, so people in those areas will see that as closing the stable door after the horse has bolted, because any proposals you make will be in the context of what is currently in place rather than what was in place before. How will you be able to engage with people in local communities, who may be disillusioned by boards and by what they see as their failure to engage with or listen to communities when it comes to service redesign in their areas?
That is another interesting and important question. The first point to make is that we are building for the future. There cannot be a single snapshot in time and we cannot get all of Scotland's health service delivery problems sorted out on a single map on a single day by March of next year. However, what we hope to do is to build a platform that is rational and logical, which involves citizens and which allows us to plan for the future, so that we have a framework that should obviate some of the problems that have occurred in your patch, in Greenock and elsewhere. This is about the future and about building something sane and rational that we can go back and use over and over again.
I listened carefully to what you said. You said that, when you go out to speak to people and get a feel for what is happening locally, you would bring those issues back to the centre and to the Minister for Health and Community Care. I presume that what you mean by that is that you may well be recommending to him that there should be a delay on a decision in a specific area until your group has had a chance to establish the parameters that the local health board should be following.
I sense the fluidity of the situation and some of the tensions, and I recognise that, even from the outside—I must use the term "outside", because clearly the advisory group was formed relatively recently and its report is not due until March, so we are giving the committee our early impressions of the work that we have been doing—there is no doubt that the geography of highly compartmentalising the decisions among 15 health boards, as John Temple said, seems a little odd. Because decisions are made in one patch and in a specific way, one might question whether such decisions are best for Scotland as a whole, or for citizens of whole regions.
For clarification, will you have a role in considering Greater Glasgow NHS Board's recommendations on the Queen Mother's hospital?
We will look at them and it is important that we do so, because we can learn from the experience of local reviews. However, it is ultimately for the minister, not for us, to take a decision about such issues. We are aware of them—
Will you make comments to the minister?
We are engaging with the people who are conducting reviews on the ground. That is one way to address your concerns—you seemed almost to suggest that we might be taking a haphazard approach to who we engage with. We are aware, just as you are, of areas in which decisions are pending and we are giving priority to discussions with those boards about the way forward.
For clarity, when you leave this room, what exactly will you do about the examples of imminent decisions that we have given? How will the mechanics operate?
We have discussed the matter during the past couple of days and we hoped that we would be able to make contact with members of the committee who want to raise problems about particularly hot areas, to see whether we might be able to set up a forum that would enable us to work with you and bring together interested clinicians, citizens and whoever, so that we can understand better the arguments that are being presented. We can also be briefed by the health board and will have full access to the papers that are now coming through. However, I would be quite interested to make a local site visit to understand the matter better.
But some of these matters are highly imminent. If we are talking about something that might happen even a month down the road, irrevocable decisions might have been taken. Perhaps you cannot tell us this at this very minute—after all, we are now into another area that I did not think we would be exploring—but what can be done just now? Given that you say that you are not in favour of an absolute moratorium—in fact, you said that that is just not possible—will you set out the mechanics of how you might address any specific circumstances that might arise within the next two weeks? If you did not want something to happen, could you do A, B or C? I just want to know what your intentions are so that things are clear in my head and in the report.
Sure. We will take our impressions from this meeting back to the rest of our group, which will next meet on 4 October. We will carry out a piece of work before that meeting. We have also booked a slot with the minister to discuss matters with him. This is our plan. We will take the matter back to the group and find out how to drive it forward. Is that sufficiently clear or does that seem a bit soft to you?
I will let other members come in at this point, because they might pursue exactly the same issue with you. In fact, I see their eyes glinting at the prospect.
Perhaps it might be helpful to put the matter into the wider context of our plans to engage the public in this exercise.
I would rather pursue the issue of urgency than the wider issue, which is not of such moment. Jean Turner, David Davidson, Helen Eadie—and Carolyn Leckie, when she returns—want to ask questions.
You have just talked about providing the committee with details of the contact that you made with the NHS work force during your deliberations. You might remember that I said earlier that certain things are happening at the moment that clinicians would love to speak to you about. You said that you do not want a moratorium, but you should be a patient that is affected by the changes that are happening now. For example, very good oncology and gynaecology units have been transferred to temporary accommodation with no thought given to providing extra high-dependency beds. A rheumatology unit that is doing a very good job and with which everyone is happy is about to be moved and a minor injuries unit slotted in in its place. This is all happening now.
No, it is all right. We in different parts of the country share the same feeling. It is fair to say that the matter is urgent in many parts of Scotland.
That point is well made. Let us think about that and take it back. Although I would love to be cast in a heroic mould, we cannot deal with things instantaneously. We must remember that what we are building is for the future—it is a platform for making decisions. The group was set up to provide the report in March. Devoted though I am to Scotland, and great though it is to come back, I have a day job somewhere, too. What we are doing takes overriding importance, but we cannot instantaneously solve every single bit of what is going on, hence the sense of prioritising.
I am not asking you to do that, but you have to be aware of what is happening and why we have hot spots, as you term them.
Indeed.
If it were a business—any kind of business: a supermarket, or what have you—the customer would be the most important person. No one is more important than a person who is very sick, and they are on a very lonely journey in the health service.
I could not agree more.
What is being eroded at the moment is faith in the system. Patients go into hospitals—big centres—and seem to be passed from pillar to post. They are not even sure who is a qualified nurse. They are in and out as fast as they possibly can be. Where do they go in general practice? Somebody has to take advice on what is happening now in order to move forward.
Thank you. I want to keep to the issue, as other members have questions to ask.
With your permission, I will ask Professor Kerr a question that I was going to ask later on, but which I think is pertinent now.
Indeed. You will be glad to hear that we are doing a mixture of the two. We are setting up a national strategic review of how decisions should be made. A common theme this morning has been that decision making is confused, compartmentalised and parochial. There is no national agreement about how decisions are made, so we need a proper framework. However, if all that we were doing was some theoretical intellectual exercise of that sort, it would be much less engaging and not something that we would get involved in. To use a crude analogy, we want to undertake part of the exercise of testing the decision making by putting pins on maps—actually making some real decisions about where the services should be delivered.
When I ask about options, it seems that different health boards are coming at the same issues from different angles. Perhaps there is a shortage of consultants or perhaps there are no anaesthetists, therefore nothing happens in the surgery, and so it goes on. The health boards are coming up with those reasons. I presume that you are not looking at any of the work force issues; you are looking at general planning of services and for people to be slotted in to deliver what is appropriate to an area. That is where you are going.
Yes, but how can we describe a vision for Scotland's health service without at least being aware of, or taking account of, the drivers for change? The work force will be one of those drivers and an aging population and changing technology will be others. I hate to sound like a technocrat. We have a matrix of work to do in which we will drive forward the themes on accident and emergency facilities, elective care, care in the community and so on. Beside that, we will have different drivers for change of which we will take account, so that when we describe what the best elective care system might be, whether it is orthopaedics, colorectal surgery or whatever, we will take account of epidemiology, the work force and other matters. We will try to provide the strongest matrix structure for the future.
I understand that, but we must take from what you said that whatever you do on the minister's behalf will have no input into the current crisis of centralisation, closures and amalgamations, because you are talking about long-term stuff.
No. I reiterate that it is a 20:20 vision, but we have said that part of that will involve putting pins in maps now and part of that will involve supporting with real examples how we can make concerted decisions throughout different health boards. An interesting decision concerns whether Scotland should have a single neurosurgical centre and if so, where it should be. The set of arguments about how we should drive forward tertiary health care is interesting. We can pick up on examples for which we would provide a detailed map of service. Those are some of the work themes that we have driven forward for making sense of in that way.
You said that it would be March before you could deliver on some of what you have described. We are reasonable people and we understand that the national health service could be paralysed if a moratorium were declared, which would have implications for staff morale and other matters. However, the time between now and March is not long, and it is reasonable to ask for a moratorium between now and March on some of the big issues, because by March, you will be able to put in place some of the indicators that will shape the big decisions about the way forward. Some decisions that are coming before us are about not just small general hospitals—about which I am concerned in my locality of Dunfermline East—but big strategic hospitals, such as the homoeopathic hospital and hospitals in Glasgow and elsewhere that cater for people in my constituency. It is not unreasonable to ask for a moratorium for only those six months.
Do you agree about a moratorium or just that it is not unreasonable to ask for one?
The statement is reasonable, but I disagree with it. I do not think that we should have an absolute moratorium, but I promise that we will try to be as fleet and quick-footed as we can be to sort out the situation. That is just my opinion. However, I understand the point.
I have found your comments illuminating. I support a moratorium—I have argued for one for more than a year, so that we can have the overall strategic debate. My questions will probably explain why. Even the Scottish Executive policy and documents that I saw when I was a member of the Public Petitions Committee provided plenty of evidence that health boards have not met their regional planning obligations, for example.
I understand that.
Such issues mean that your work is urgent. You can probably sense the committee's desperation and can perhaps understand why you are being seized on as a bit of a saviour and why the work of your group is perceived to offer a way out.
Do not frighten him any more.
We do not want you to leave this room without recognising the strength of feeling that exists. I would welcome the opportunity to be able to give an even deeper explanation of the situation and I am sure that all of us would like to point you in the direction of sources of information other than just the health boards.
That is fascinating. I want to make two important points. The minister has encouraged us to be as visionary as we can, so there are no barriers. We have been told to push the envelope in thinking about how the service will evolve and reconfigure over the next two decades and how we can underpin that process with the best modernising ideas. For example, we need to consider what we can pinch from Canada, which has remote rural outreach. The committee should take comfort from the fact that we have been invited to think laterally.
The national debate is running ahead of you. In an ideal world, you would have your route charted out and you would have gone down that path, but people are cynical. If people hear the word "consultation" again, faces will turn away. Time is running out. Those are fine words, but, with respect, the debate is now; it is all over the newspapers and in our mail trays. You spoke about the consultation in Tayside and there are others. As Duncan McNeil mentioned, people feel that such consultations are just cosmetic exercises.
I will just follow through that point, because it is important. Our concern is not just about a perception, it is about material issues. Our worry is that the objectives of your report may well give us a basis for developing a strategy, but it is clear that current decision making and its outcomes may well be fatally flawed, if judged by your terms of reference. However, we cannot go back and unpick things.
The point is well made.
It has been ruined now.
Can we speak through the chair, please? Shona Robison and Duncan McNeil want to speak.
Helen Eadie is a reasonable person and I agree with everything that she said. The request for a suspension of decisions that are pending to allow a national debate and better public engagement is not unreasonable. If we do not do that, we will have a national debate with a very cynical public. If we meet members of the public in areas where services are closing to engage them in a national debate about the health service, they will just say, "But services are closing. The decision has been made to close or downgrade a hospital."
May I reflect on a moment of cross-party unity? Shona Robison makes an important point on the credibility of the planning process and the national debate. We have broad agreement today, which is necessary, about trying to create a debate while local decisions are being made. We are reaching out to you to consider the matter. We are not saying that work should not proceed—services are monitored all the time anyway—but it would be damaging, during a national debate, for a health board to come out with a decision that the community found detrimental. The credibility of this committee, of the minister and of everybody else would be affected by that. I urge Professor Kerr to consider seriously the cross-party view that has emerged today.
I sense it intellectually and sympathetically. I understand exactly where you are coming from and the advice is good advice. May I take it back? Neither Derek Feeley nor I are empowered to impose a moratorium on anything.
You are not, but your views are valuable.
Exactly. Your views have been strongly put. We understand them and we share the majority of them.
To back up what Duncan McNeil said, we have a date in the calendar for the implementation of the new out-of-hours services; that is set in law and it cannot be undone. The urgency on the matter is coming loud and clear from each of the many communities that I have been in touch with. Some communities are saying, "We like the proposal because we are in a town, but we have a wee concern." Others are saying, "We cannot cope with this idea." Local doctors are saying that they think they will get lynched. That is a public debate about the roll-out of a service. The health boards are in charge of the consultations and they came up with the models, but it appears that they are not doing anything other than driving a budget. There is a meeting in Grampian tomorrow. I am trying to convey the urgency—there is to be a national debate, but the issue is on the national agenda now.
I am troubled by the depth of cynicism. The point is well made and I accept all that you say. I understand it. Being bombarded with the newspaper headlines in the past few days started me thinking along the same lines as you.
I will stop the questioning there. We have reached an important point. We do not expect you to make decisions here and now, of course, but it would be helpful if you could write to the committee, hopefully in time for next week; we will not have a meeting next week, but we will have an away day. It would be useful for the committee to have your views, following our discussion today, on the best way forward for everyone.
Indeed.
There would be no guarantee that any community would keep its accident and emergency facilities or whatever, but if there were to be a suspension until your report was published, it would be honest to say that, pro tem, nothing would happen until we had considered the matter on a national basis and come back. We fully support that idea. That would be fair to people all round and it seems to be common sense, given that you are doing such important work.
I am happy to do the second aspect of that, on engagement with the committee and petitioners, but I am not clear about what you are asking us to do in your first request. To reiterate what Professor Kerr said, neither of us is empowered to make a decision about—
We are not asking you for a decision. We know that it is the minister's decision, but we would like your views. I do not want to write the letter for you, but we would like your views, having come to Scotland and seen what is going on—it has been going on for a long time—against the background of work that was perhaps commissioned without awareness that the issue was going to explode. We would like a rethink about the method and your recommendations about what is required in the meantime—that is all. We know that that is all that you can do.
We have heard with great clarity what you have said, and the common sense and wisdom here. We will reflect on that and we promise to bounce a letter back by whatever date you said.
The away day is next Tuesday.
We will do it.
That would be useful for the committee to discuss.
Meeting closed at 16:10.
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