Health Committee, 20 Sep 2005

Meeting date: Tuesday, September 20, 2005

Official Report 317KB pdf

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National Health Service (Framework for Service Change)

Agenda item 4 is a discussion of the national framework for service change in the national health service in Scotland. Following the publication of the "Building a Health Service Fit for the Future" report, which was produced by Professor David Kerr's national framework advisory group, the committee agreed to invite Professor Kerr to give evidence on the report. I welcome Professor Kerr to the meeting.

The committee agreed to give those who participated in the public debate earlier this year an opportunity to submit questions from which committee members could draw during the session with Professor Kerr. We have had a big response to that request. Members will pursue a number of issues with Professor Kerr, but we will not be able to cover all the issues that members of the public raised. Several people who attended the public debate are here today to listen with interest to Professor Kerr's evidence—I welcome them, too. If they submitted questions, they may hear questions from members that relate to their concerns.

Professor Kerr, I ask you to make a brief introduction, after which we will go straight to questions.

I will be brief. I would just like to thank the advisory group, which supported me through the year when we pulled the framework for service change together. I also thank the citizens of Scotland who came to our public events to make their contributions, thus strengthening the report significantly. Finally, I thank the front-line forum: the health care professionals, nurses, doctors and others who raised their voices in concert and strengthened our report. The report came out well, but it was definitely improved by the fact that we listened to people, which engendered a broad spectrum of support.

Thank you, Professor Kerr. We will move straight to questions. Several members have already told me what areas they would like to cover. I will go straight to Mike Rumbles, who has questions about neurosurgery.

Professor Kerr, your report has been welcomed across the piece. Its message of a new way of delivering care and of planning centrally but delivering locally has been warmly welcomed. However, I know that the detail of some of the recommendations has caused alarm—I do not think that that is too strong a word—in the north-east of Scotland. For example, you say in paragraph 2 under the "Key issues" heading:

"For neurosurgery the recommendation is to move, over time to a networked approach from a single hub."

You also remark later in the "Key issues" section that some highly specialised services should be delivered

"on one or two sites in Scotland."

I was at a meeting yesterday with the Grampian NHS Board in preparation for this meeting. The board thought that your proposal would be a huge mistake for neurosurgery. In almost every other area, you are delivering locally, but in neurosurgery you are focusing on central sites. People in the north-east feel that those recommendations would have a dramatic effect on patients for neurology and orthopaedic surgery and on recruitment and retention at Aberdeen medical school. The report's recommendation for patient pathways focuses on the patient, so would it not be a major error to focus on one site many miles from where patients are?

Let me respond in two ways. One is to set out some broad principles that underpin the philosophy of centralisation, which I have a sense you have reservations about. Let me also be specific about why we adopted the recommendations that we did on neurosurgery.

One of the great areas of debate among the public and this committee has been the fear of an overcentralisation of services that is not driven by any obvious or compelling logic. Throughout the report, we have said as often and as rationally as possible that we would prefer to treat patients as close to home as possible. However, we also say—and we asked about this at our public meetings—that there are some clinical conditions and some types of treatment that are better ordered and better delivered from a smaller number of centres. Scotland's population is relatively small, although we understood that we had to find a solution to the problems of geography and of Scotland's remote rural communities.

There was a great deal of debate with some of my clinical colleagues about whether there was evidence that, if people were treated in a single centre—I use that model as an example—they would live longer and better. There are compelling hard data suggesting that that is the case in complex neurosurgical, cardiac and some cancer procedures. The evidence is strong and I am quite a difficult person to convince, as, no doubt, are you.

We felt that we could marshal strong, compelling data on neurosurgery that would allow me to go into the lions' den—the medical school in Aberdeen or wherever—to argue our case. The evidence would strike a chord with the senior medics and health care professionals involved. We thought long and hard about the matter.

Professor Graham Teasdale, the president of the Royal College of Physicians and Surgeons of Glasgow, chairs the intercollegiate group in which the different colleges come together. By chance, he also happens to be a world-famous neurosurgeon. He carried out the work on volume and outcome. If we have good evidence that suggests that we should focus on centralising the services for some of the conditions that have been mentioned and if we can make sense of that evidence for the citizens of Scotland, I believe that people will be prepared to travel to receive those services. Indeed, they have told us as much and we have responded to their comments in the report.

Why did we model neurosciences and neurosurgery? When I first took on this job, the secretariat had strong representations from the chief medical officer. I asked him to give me examples of decisions regarding service redesign and reorganisation that have been almost impossible to take in Scotland. I said, "You probably have a shelf full of such things. Why don't we take down a couple, blow the dust off them and see whether we can work up a process or framework that will allow us almost to reach a decision on them?" The chief medical officer chose neuroscience and neurosurgery and paediatric services, and we modelled those aspects.

Each member of our advisory group took on a different work stream. The neurosurgery work stream was chaired by the director of the Royal College of Nursing, who worked with professionals from each of the major medical schools and centres in Scotland and brought in external experts to work on the evidence base and filter the evidence that was being received. However, because all the ducks were not quite in a row, he could not be precise and say that the centre should be established in Glasgow, Edinburgh, Aberdeen or wherever. Basically, although I was twisting the group's arm to put a pin in a map and validate its decision to me, it did not get quite as far as being able to do that.

Until we had this discussion, I thought that there was broad consensus among professional bodies and centres, including Aberdeen medical school, that are interested in delivering neurosurgical, neurological and neuroscientific care to the people of Scotland. We are not proposing that everyone who requires a neurological or neurosurgical opinion should go to Glasgow, Edinburgh, Dumfries or wherever it is decided that the centre should be set up. Instead, in keeping with the first premise that I outlined, I believe that we should have tiered care that would allow patients to receive as much care as close to home as can safely be delivered. Of course, Aberdeen is a dead important component in those different tiers of care.

If we have a hub-and-spoke model instead of what might be better described as a partnered network, the hub will have special characteristics and needs in order to deliver care for all the folk of Scotland. I think that I can produce evidence that would convince the committee and the folk of Scotland that they would get a better deal if such care were delivered from a single site.

Thank you for your response. I have to say that I entirely agree with the general thrust of your remarks. Your report suggests that care should be provided locally where it is safe to do so and that, if detailed procedures such as neurosurgery are provided more centrally, people will benefit. However, I did not take from your response that we should go further and provide care from a single, central hub. We have some fantastic hospitals in Scotland and all the information that I have received suggests that there is absolutely no reason why we should not have hubs in Aberdeen, Glasgow and Edinburgh.

Although I am sure that we all agree with your general philosophical approach to this matter, I am worried that implementing your recommendations in practice will just pull things apart. For example, there is a real danger that care provided locally in X, Y or Z might get sucked into a single centre. Surely that cannot be your intention.

What we need is tiered care. You are right—not every neurosurgical patient, neurosurgical operation and neurological opinion can be dealt with at a single site in Scotland. I agree with that entirely. However, there is a certain portfolio of operations, investigations and tests that it would be sensible to do in one place. As is always the case, the majority of treatments can be delivered in Edinburgh, Aberdeen, Glasgow and Dundee, but we need referral pathways and guidelines with certain conditions that can only be dealt with in one type of centre. I would not want to abandon those conditions for which there is a clear relationship between volume workload and outcome. However, the data were compelling enough to show a well-described basket of investigations and treatment that are better delivered from a single site.

What you said was very interesting in that, when push comes to shove, it is fine for us to sit around and talk in theoretical terms about how we are going to have graded neurosurgical care and how everything will work together, but when someone says, "Well, that means that you will be doing this and he will be doing that, but this centre here will be doing a bit more of the other," that is when things start to disintegrate. There is a need to balance narrow self-interest—I am not saying that that is true of the specific case that you mentioned—with the national good if we can provide the evidence that supports the proposal. It should not become a case of "Yours is bigger than mine" or "Mine is shinier than yours". If we can provide hard facts—and I believe that we can—that should be compelling in a wider decision-making process.

I would like to pursue that point. When we took evidence from Professor Teasdale and the royal colleges, the question was asked when it is completely safe to do something at a central location. The logic is that, if things are centralised, they become safer, because the surgeons have more practice. However, you are not saying that.

No.

We have good hospitals in Dundee, Aberdeen, Glasgow and Edinburgh that could cope with being centres of excellence. My worry is that, if you are now pursuing the idea of a centre of excellence for the greater good in Scotland, so that people go to one place to get the best care, we will go back to the position that we were in before. If we concentrate investigations and treatment in one place, we might get the best possible care, but that will not help the patients in Dundee or Aberdeen—or, indeed, in Glasgow or Edinburgh if the centre is up in Aberdeen.

Forgive me, but you are oversimplifying and polarising the issue. I think that you and I are broadly agreeing with each other. Tiered care can be safely and well delivered from each of those impressive hospitals that you mention. I have visited those worthwhile places, many of which have national and international standing. We have no problem in agreeing on that.

However, there is strong evidence that if some—not all—neurological procedures are delivered from a single centre, the people who are treated there will live better and longer. Without going into a lot of detail or using many statistics, we are talking about toleration of risk. For many of the things that we do, the evidence mandating a central drive is pretty slight.

I think that sometimes there is a tendency to do a bit of shroud waving and to say, "If we do not centralise, the wheels will fall off and people will be dying." We sometimes hear such amplified and hyperbolic stories. I agree that that is not the case. The majority of common treatments can be done equally well in Fort William, Dundee or wherever.

The citizens of Scotland have posed the same question. They want to know what treatments can be delivered safely close to home and what they might need to travel for. They say that, if there is good evidence that they will live longer and better, they will travel. We have looked at the evidence as closely as we can. I would not stick up for something unless I had the figures to back it up. There is a lot that I would not try to defend. We have said, "No, let's keep that network model there."

I agree with you 100 per cent that people want local care but that for major issues they are prepared to travel. However, I thought that you were saying that not in relation to our community hospitals in Aberdeenshire or Fort William or wherever, but in relation to the major hospitals in Scotland—in Aberdeen, Dundee, Glasgow and Edinburgh. I did not think that there was an option of cutting back on our major hospitals and going to one centre. That is the nub of what I am trying to get across.

That is an important point. Perhaps neurosurgery is a bad example. We are talking about a narrow portfolio of work that undoubtedly would be best delivered in a single, well-equipped centre with paediatric and other support. That does not take away other neurosurgical procedures that will be done in Aberdeen and Dundee, for example. However, given Scotland's size and population, undoubtedly we would have better outcomes if we focused a significant but narrow amount of neurosurgical work in one centre.

Yes, I expect the people of Scotland to trust my report and to travel for that particular portfolio of work. Other neurosurgical procedures can be performed well, safely and effectively in the other places to which you referred. It is a question of degree. We agree with each other, but for some rare cancer operations, transplants and other such procedures, we probably need just one centre in Scotland. I firmly believe that, if we said that and had evidence to back it up, the citizens who are sitting behind us would buy into it. We are in agreement.

Can I turn that on its head and cut away from all this agreeing with each other?

I was not agreeing.

I noticed that you were not.

I will turn the argument on its head, in relation not just to neurosurgery but to all the other things to which you might apply it. The other side of what you are saying is that, right now, procedures are being carried out in our hospitals that are either unsafe or are not going to deliver the outcomes that they should deliver. Right now, in a variety of hospitals around Scotland, things are happening that, according to your advisory group and all the doctors, are detrimental to patients. Is that what you are saying? I do not want a 15-minute answer, Professor Kerr.

I will give you a very precise answer. The relationship between workload and outcome is narrow and exists for a relatively small number of clinical procedures. The evidence supporting the centralisation of a host of common procedures is not sufficiently strong for me to be able to say that those procedures should be centralised.

Currently, four centres carry out neurosurgery. Are you telling us that some of those centres are not performing in a way that is in the patient's best interests?

I am saying that they could perform better if some of the work that they do were to be centralised at a single site.

Each of those four neurosurgical centres is attached to a medical school. Has any consideration been given to the impact on the medical schools of removing the services?

We have not had that discussion, so I could not reasonably comment on the impact.

To be fair, and if we are to move forward, we should acknowledge that the report is about give and take. However, my concern lies with the point that you ended on. I hear your argument and I do not doubt that the statistics exist to back it up. However, many of us are concerned about the consequences for remaining services if you siphon off some services—not just neurosurgery—to a central point. The issue is not as simple as saying that only a basket of procedures will be taken from existing centres and the rest will be left. My appeal is for further work to be done to reassure the centres that are not centres of excellence that there will not be a knock-on consequence on their other services. The last thing that any of us wants is a cascading situation in which other services are under threat. I am sure that you do not want that, either. That work has to be done and the reassurance must be given that the neurosurgery proposal will not have unintended consequences.

I fully support the general principle of what you say—that many if not all disciplines in modern medicine are interrelated and that, if one kicks one pillar away, the temple will come down.

I am not a neurosurgeon and I was not on the neurosurgical committee. However, as far as I can tell from the general buy-in to planning and movement towards the proposal, the representatives from each of the medical schools and clinical centres believed that the negative impact on existing centres would be minimal. They saw the proposal as a strengthening—

No.

I can only report what came back from the working group. Clearly, concerns have arisen since the report went to press, but, until that point, it looked as though there had been remarkable consensus building to sort out a thorny problem that has been sitting on the shelves of the Health Department for years without anybody making a big effort to tackle it. I can only tell members what the situation is. I agree with the general principle of what you say, but I think that the neurosurgical proposal would have a pretty small impact.

I suggest that we need to take further evidence on that point.

That is possible. In response to Professor Kerr's point, I should say that, when I met members of the Ninewells team before the recommendations were made, they expressed a great deal of concern and alarm about what they saw as an inexorable process that was just grinding on to get the result that had not come out of the past three reviews but that they believed was always wanted from the start. I do not know whether that is the view in Grampian.

Nanette Milne and I were at Grampian NHS Board yesterday where it was put to us forcefully that the proposal is a major concern. I agree with Shona Robison that the committee needs to take more evidence on the issue.

We will take evidence under advisement.

There really was a sense of important consensus building among the group. What has not existed in Scotland until now is a national planning framework or means of deciding on such issues. As has been said, these problems have been hovering over us for some years without resolution. We, the citizens of Scotland, need that resolution and we have come close to it. Not to accept that feels like a step back and not the step forward that we are hoping to make with our recommendations.

I am conscious that we have spent nearly 25 minutes on one issue, so I will jump to Duncan McNeil, who has questions about health inequality. I will come back to other members about related points.

The report raises issues about effective health care, narrowing health inequalities and decades of underfunding. Perhaps it is because the people who are dying in my constituency are 50 and 52 years of age and there is a general life expectancy of 64 that they do not form campaigns. They do not march on Parliament because they are grieving privately. The report is significant in what it says about what we can do to improve the situation in communities such as mine.

Health inequalities give rise to issues such as access to general practitioners. The most affluent and healthy people in Scotland are looked after by the same number of GPs as our poorest people, who are in greatest need. Also, effective health care interventions are more likely to be delivered in healthier areas, which widens the gap between the healthy and the unhealthy.

I will go over my questions. First, what can be done to increase GP numbers in frontline areas where there is a clear need? Secondly, what action will be taken to ensure that future initiatives in primary care do not follow the precedent of being taken up twice as often in affluent areas as in poorer areas? Finally, how will your report help to address the relative failure of the distribution formula to provide for primary care services to address unmet need in deprived areas?

Those are important issues. I know your constituency and the questions are entirely relevant. When we wrote the report, we were thinking about the 15 or 16 lost years of life. If my son were born in Oxford tomorrow, he would have a median life expectancy of 82, but if he was born where I was, in Maryhill, he would have a median life expectancy of 64 or 65, as you said. That is neither tolerable nor sustainable. We are lucky that Harry Burns, who is Scotland's chief medical officer, has studied health inequalities and what underpins them. He supported us and helped us devise a means of reaching out, which is what is required. We cannot passively wait for those who are disadvantaged or less well off to access the health care system, because we know that they do not. There is an argument about mountains and Mohammed. What is required is what our report calls anticipatory care, which means going out to find cases and bringing people in to the system. In my field, which is cancer, patients from less well-off backgrounds come with cancer that is more advanced, which means that it is more difficult to treat. When they do come, they do not get access to the same treatment as people who are better off. At every point in the system, they get another kicking.

We want to employ a new type of primary care professional who case finds; they will go out and encourage people to come in for health screening—to have their cholesterol level and blood pressure measured. We have done some calculations, of which Dr Turner will be aware, that suggest that if everybody who needed one of the drugs that prevent heart attacks got it, we would save hundreds, if not thousands of lives in Scotland every year. However, the folk who need those drugs are out in the schemes, they may be on their own and they think that screening is not for them, whereas those who are better educated and who understand the system access everything that is going. That is partly by virtue of their knowledge and drive, but also because of the density of general practices in their areas.

Your original question was underpinned by the question whether we should skew the new measures in some way. It seems entirely logical that, if we bring in a new group of health workers for anticipatory care, we would load the funding towards the communities that are, to be blunt, designated the poorest. We have discussed and thought through such a measure. I am sure that Dr Harry Burns, as CMO, will be keen to model and make progress on that suggestion in some way. We need anticipatory care so that the right folk are encouraged to come in for the right treatment.

That feels like a short-term answer to me; the longer-term issue for all of us is about citizens starting to take responsibility for their health, while we educate and support that. I hope that one of the results of the community health partnerships—through which local authorities, social work and education will work together—will be that we start to inculcate a sense of reaching out in an educative way that incentivises people to look after themselves, to avoid the wrong sort of food, to stop smoking and all the rest of it. Everybody knows what is wrong, but we need to reach out and emphasise that in a way that really counts.

On your final point, I do not know enough about the details of the Arbuthnott formula. The formula delivers big chunks of money to the health boards. A component of it is supposed to take account of postcode and relative levels of poverty. You are suggesting that that is not working strongly enough; I am not able to deny that. It would be entirely legitimate for us to ask Sir John Arbuthnott to go back and study the formula to see how that is delivered. I truly do not know enough of the details to know how it does or does not work.

But you agree that the status quo is not an option.

I do.

To continue to provide for those who are healthy will not narrow our health inequalities, but make them worse.

Yes.

We can get a short-term hit though. We can quickly prevent people dying.

We will. I refer to some of Harry Burns's ideas on heart attack prevention. Heart attack is still the biggest killer in Scotland. We can do a lot to bring down high blood pressure and elevated levels of blood lipid, called cholesterol. Modern drugs can reduce hugely the risk of heart attack and save hundreds and thousands of lives. That will be at the forefront of anticipatory care.

I turn to the community health partnerships. The model is local, but in constituencies such as mine there are affluent areas as well as a number of deprived wards. Can we be assured that CHPs will be able to deliver for poor people in smaller, defined areas? How will we ensure that the partnerships will deliver for those in most need?

Why do we not ask them or tell them to? The community health partnerships hold great promise. We know roughly what they want to do, but we have a pretty empty page when it comes to exactly what their targets should be. We have suggested what they should be; why do we not ask or tell them to do exactly what you suggest? We could say that they have to reach out, distribute, reduce inequities and consider the anticipatory care model. Why do we not ask the Executive to make that a must-do?

I know that other members want to ask specifically about community health partnerships and at least one of them wants to cover other issues. I ask Nanette Milne, then Helen Eadie, to address community health partnerships specifically at this stage. I will allow them to come back on workforce planning issues.

How do you see the community health partnerships developing? Everyone in a community health partnership has to be committed to it if it is to come together and work properly. Do you see general practitioners, consultants and other professionals breaking down the professional barriers and coming together in the partnerships? That could be crucial to how they work.

My other question is about funding. Your report mentioned CHP fund holding, for want of a better expression, and collaborative contracting. Will you expand on that?

There are no community health partnerships in England, so I got to learn about them here. They hold great promise and, as with everything, they have strengths and weaknesses. The strength is that they will be embedded in the community; they will know what local needs are and will be able to work with other agencies, such as social work departments, the police, education authorities and so on. They will be strongly focused on geographical patches. The people in the CHPs will know their patch better than anyone in St Andrew's House or some other central place ever could. There is enormous strength in that. Their flexibility and ability to adapt to local problems is another strength.

One of the worries that we had—although that word is perhaps an overstatement—was that we felt that there were key deliverables that were required of all CHPs. As Mr McNeil said, we felt that there were some must-dos, which are not about the imposition of a central menu of things that the CHPs have to do but around areas such as anticipatory care, looking after patients in the community and developing models for the long-term care of patients with chronic conditions.

We said with some clarity to the CHPs, "These are the must-dos that we expect you to take on. Within that, the next five things that you can do have to be flexible in response to what your community needs and how things move forward in that way." We were trying to strike a balance between saying, "Centrally, these things are awfully important for the country as a whole, but you must also have enough laterality to be able to engage with whatever your local community needs." We tried to strike that balance and to move it forward.

The point about breaking down barriers is incredibly important. We need clinical engagement on these issues. When we were on our travels, one of the things that we came back with was a nascent sense of anxiety about what the CHPs would be and whether they would dilute the voice of the local clinical leaders.

We heard that the existing local health care co-operatives were working and that there were good relationships between secondary and primary care. Although folk could see the potential advantages of the CHPs, the clinical fraternity and sorority are a bit nervous of them. Therefore we—the CHPs—need to work exactly as Mrs Milne suggests in order to ensure that the barriers do not go up again.

If we are serious about trying to manage patients with long-term chronic illnesses, the only way to do that is by developing care pathways that go all the way from somebody's home to some very fancy hospital wherever it might be—as locally as possible, but it might be somewhere distant. The only way to get the pathway to work is by breaking down barriers between primary care—looking after folk at home and in the community—and secondary care. That is the big prize of the whole report—challenging the culture of the rather segmented way in which we look after folk at the moment. Folk just do not go seamlessly through anywhere at all. The CHPs have got to be absolutely fundamental to dissolving barriers, keeping an eye out and keeping all that stuff happening.

In terms of Mrs Milne's second question, about funding, I was talking around how we incentivise and drive forward change. It is all very well for me and the team to write a report that is motherhood and apple pie to everybody, but unless there are levers that we feel we can operate to make it happen, the report will go back on the shelf again and nothing else will happen. The report does not deserve to ebb away; it does not deserve that in terms of the effort that we and others put in to get this sorted and in terms of the buy-in that we have seen for it.

I was talking about whether we could borrow examples from elsewhere. The debate is about a significant redistribution of what I will call the balance of power—and I probably mean that—away from secondary care. I work in a hospital in an ivory tower. I suck huge amounts of resource and energy into the hospital because it is my kingdom, but only 10 per cent of all care goes on in that way. I was talking about trying to find ways in which we could legitimately balance and say, "There's got to be more of an equal partnership in how patients are looked after." That is why we looked at collaborative contracting.

Take the example of a diabetes consultant who has some sessions in a hospital and others in community hospitals or general practice. I am thinking of somebody who is involved in training diabetic patients to look after themselves, helping their families to help them and so on. It should be regarded as a failure if a diabetic patient ends up being admitted to hospital. It should be that the system has let the patient down rather than, as sometimes happens at the moment, we suck patients into hospital. If somebody had that sort of a contract, they might feel, "Oh, I am owned by the hospital and by primary care." That might be one way of doing it.

In terms of how money moves through the system, I was just putting some small ideas up about how we might introduce grit into the oyster—to use a slightly odd English term—or contestability. That is all the buzz down south just now. However, a model that is based completely on contestability in the market is not right for Scotland. I have said that before and I mean it. We have a more collective approach to health, which fits in with how we are as a society, with our history and with the way in which we can get our hospitals, GPs and so on working together. I was just flagging up some general ideas to see how the Executive responds. I have no idea how it will respond.

Is there a risk that the CHPs will be too big to allow the collaboration that we are talking about?

Some clinicians are worried that they will be diluted in a large organisation in which their voice carries less weight. I keep saying that clinical engagement in the widest sense is dead important to the cultural change that we need to get this forward.

The answer is "maybe", but the CHPs were chosen pretty carefully to try to represent joined-up government. Again, I do not know enough about the geography of the CHPs. The issue needs to be resolved, but my sense is that the geography of the CHPs is about right. I do not think that I would want more CHPs or smaller ones.

I have to say that I am still reeling at the idea that we are going to get consultants out of their ivory towers to work in medical centres. At the moment, we do not appear to be able to persuade them to travel from one hospital to another, much less into the community. If that is the plan, there are some massive hurdles.

I come from Fife, which is, outside Glasgow, one of the biggest areas of deprivation in Scotland. It was formerly Scotland's biggest coalfield community. We had what the Scottish Executive regarded as a model LHCC. Since the inception of community health partnerships, great suspicion has grown up among clinicians. I have engaged with GPs and consultants and they are concerned about the change. I am not persuaded; you have introduced something new, but there was already a good model in place. Given that the LHCCs worked, I cannot understand why you have thrown them out. There is an argument that if something is not broken it does not need to be fixed.

I represent a village called Lochore, which is 103 per cent above the Scottish average for disability and sickness. That might be hard to believe, but it is a fact. My concern is that there is not a single NHS dentist to be found in that area. Some 15,000 of my constituents received letters to say that they will no longer have an NHS dentist. The relationship between gum disease and heart disease is clear, but no thought is being given to that. How will the community health partnerships address such issues?

Helen, there is a point that needs to be made. LHCCs were abolished under Executive legislation in an act that I think you must have voted for. It is not something for which Professor Kerr was responsible.

Primary care includes dentistry, chiropody, opticians and so on.

Professor Kerr is not responsible for the decision to move away from the LHCC model. That was an Executive decision.

We did that.

Yes. In effect, the partnership or the Parliament did that.

The question is to what extent there is still a possibility of using the model that was in place. That brings us back to a point that was made by Dennett. The British Medical Association and others have written to us about their concern that clinicians will not be engaged in the way that they were with the LHCCs. That is the point. It is about getting clinicians and consultants engaged in a way that will deliver for communities.

I pick up on what the convener said. I understand the sensitivities and I detected them too. I inherited the community health partnerships, as did you. I just want to make them work. We detected the same doubts and worries as you. That is why we said that clinical engagement is critically important and that the community health partnerships must get on the front foot with that immediately because otherwise that engagement will be diluted and will waste away. I hope that we can use the community health partnerships—

May I interrupt you for a moment?

Of course.

I want to make a more refined point about GPs and how we know whether they have had the new contracts, which seem to be silent on a whole range of issues, such as the delivery of osteoporosis diagnosis and treatment centres. Skin disease is another such area—there are people in the public gallery who represent psoriasis and dermatology interests. People are not convinced that there will be diagnostic facilities for skin conditions, because the GPs contract does not allow for that.

I am not sure. Is your question about how GP contracts—

Your report says that community health partnerships will provide diagnosis and treatment in the centres, without people having to go to hospitals, but if you cannot get dermatology services delivered locally because the GP does not have that in his contract, or if GPs cannot diagnose osteoporosis because that is not in their contract either, how can the CHPs deliver those services? You are talking about services being delivered in the community, rather than in a big hospital building.

I understand your point. It may sound a little lame, but you have got to start somewhere. When I initiated the national cancer plan in England, that was because I was a cancerologist and because cancer was a huge big killer. It was really important to everybody and it was a number 1 priority. I have not been involved in the way in which the GP contract was set up, but I think that you are right in saying that it has been biased towards developing points for the big killers, or the big-ticket items. If that has in some way disadvantaged those who suffer from a multitude of other diseases, that feels completely wrong. I guess that that was a start, or a first shot at the issue, but I would imagine that, when further contractual negotiations come in, people will have to pay attention to the broad spectrum of diseases. I guess that people had to make a start somewhere, but I understand your point, which is important.

I want to move on to workforce planning issues now. Nanette Milne and Janis Hughes have questions on that.

If the local delivery of health care and anticipatory health care is to work, it will involve a huge amount of workforce planning. People will have to get used to going to see not just a GP, but teams of people, and there will be lots of involvement of allied health professionals. We already have difficulty in recruiting GPs in certain parts of Scotland, and we have significant difficulty in recruiting consultants to certain specialties, not only in Scotland but globally. The Royal College of Nursing says that we are training for replacement but not for expansion of the service, and we will presumably need more specialist nurses in future. Physiotherapists are saying that they do not have enough training posts for people coming out of college. Such concerns are being voiced by AHPs of various kinds. Could you comment on that? One or two specific points were raised with us, which I might ask you about afterwards.

That is a critical set of questions. I know that the committee has received reports from Sir John Temple and from Sir Kenneth Calman, who have looked at clinical workforce planning and at medical training, to give you some idea of what measures have been put in place to expand student numbers and how training places will be improved for clinicians coming through.

There are two elements to the issue. One of the things that we tried to bring out in the report—I am paraphrasing Don Berwick—is the need to work better, not harder. If we can improve working practices and redesign service delivery, we hope that we can improve the quality of service that we deliver and that those who deliver it will feel happier about what they are doing. The status quo cannot continue. People feel that they are constrained to deliver a second-rate service. We are asking clinical groups, in the widest sense, how they can use their intellect, power and energy to redesign services and make them better. We want to set people free to do that. That will play an important role in rewarding people, incentivising them in their own sectors and segments of care to do the very best that they can with the resources that they have just now. We want to do the best that we can with that which we have.

I found your question on multiskilling absolutely fascinating. I have gone round Scotland, as I am sure you have done, and seen many of the excellent and innovative ideas for the upskilling and retraining of a whole host of different health care professionals. My father was an ambulance driver, and when I was a medical student I would go out on the night shift with him on the south side of the city. We saw some extraordinary things. We would pick up people as quickly as we could and shoot off to wherever it was—I almost said the Victoria infirmary, but I am glad that I did not. Oops, I just did. My brother now manages a big bit of the ambulance service and I am terribly impressed by the skills of modern paramedics. Graduates are being attracted. In the old days there was a steady trickle of people; now there are waiting lists. By getting the right people doing the right thing, and by training them, giving them confidence and setting them free, a huge amount can be achieved.

I was impressed by the telemedicine centre in Aberdeen. They gave us a demonstration of a paramedic in someone's home, managing a heart attack much more effectively than I could. That was governed closely by a consultant working in the accident and emergency unit in Aberdeen. The electrocardiograms came through, and it was a perfect example of what we can do if we ask how we can use people who have a set of skills that we can amplify and that we can link in. It always comes back to linkage and collectivism, and getting things moving forward in that way.

There are some excellent people out there. Scotland has a vision of upskilling and uptraining, and of bringing other professionals to the game—in terms of first responders—and working closely with them. Retention is an issue, and I guess that we will discuss remote and rural communities. It is desperately important that we make those jobs attractive so that high-quality consultants and general practitioners want to work in remote and rural communities. I heard some good ideas about how we could do that, such as financial incentivisation, quality of work, training and simple things such as how we advertise for those sorts of posts. There are lots of good ideas out there about how to get new people in, how to get them where we need them and how to hang on to them.

Are the resources there to train all those extra people?

Yes.

The Royal College of General Practitioners has asked the following question:

"Your report acknowledges the increased importance of the medical generalist and general practitioners with a special interest as part of service redesign. How do you envisage this being achieved given the anticipated shortfall in the general practitioner workforce and the limitations on the number of training places available to train general practitioners?"

Thought needs to be given—and is being given—to career training structures. I do not know whether it is true, but I read in the papers a few days ago that the BMA says that thousands of doctors down south are unemployed; that is junior doctors who could not get on the career training grade. There is a big question mark over that, but if it is true we need to resolve it. There is no point in having GP and consultant jobs available, and in training lots of medical students, if the bit in the middle acts as a bottleneck rather than facilitating. I do not know enough about that, but it seems illogical.

I am told that it is a significant problem south of the border but not yet in Scotland.

I hope I am not being parochial about it, but if that is the case perhaps we can take advantage of that and make Scotland an attractive place, so that the brain drain comes from England up here rather than, as always, leaching our medical students down south and elsewhere. There may be a window of opportunity that we can use. It is daft if there is a bottleneck; we need to understand it and see what we can do to expand the number of training posts.

We met some wonderful GPs in remote and rural communities—GPs who wanted to go the extra mile, who wanted to be able to attend road traffic accidents and resuscitate and who are saying, "Train us. Give us new skills. How can we work more closely with our hospital colleagues?" There are excellent examples at the Vale of Leven hospital and in Fort William and so on. We encourage that. We want the colleges to get together and to come up with attractive training programmes that would facilitate and support training rural GPs.

Janis Hughes wants to come in on nurse numbers, but Duncan McNeil had his hand up to ask a question on this.

I have a question on the equalities theme again. How do we tackle the fact that two thirds of the training capacity for general practice is based on the affluent half of Scotland? There is a major issue there about training people to work in areas of need. I am a supporter of upskilling. I am quite convinced that there are many workers, such as allied health professionals, who are desperate to take on some of those jobs. In such areas, where people often have more than one illness—they might have diabetes and heart disease, for example—can we be assured that the health professionals can cope with that level of challenge?

I was not aware of the statistic that you just gave and I hope that I can say this free of political connotation. Should it take affirmative action to get that balance right? We would be more likely to retain GPs in areas of need if they were trained there, understood the problems and realised how worth while it was to be embedded in the community and to play a significant part in improving health. Why do we not take affirmative action to get the ratio right?

Your group gave close consideration to workforce issues, especially the external factors that are driving the need for change in the NHS today. You focused heavily on the medical profession, but I know that you also looked at the work of nurses, allied health professionals, admin and clerical personnel and other ancillary staff. It is worth noting that more than three quarters of the workforce in the NHS is female and that a large number of those females are employed on the nursing side of the profession. A moment ago, you said that thought needs to be given to career training structures. You were referring to medical staff. Does the same apply to nursing staff?

The Association of Scottish Colleges suggested that the NHS might be too preoccupied with degree-level entry qualifications at the expense of learn-as-you-go training. When I trained as a nurse, we did on-the-job training and received a salary for our work. My view is that we are disfranchising a large number of people who would make excellent nurses, but who might not want to follow an academic route into nursing. I feel that increasing the number of people who are available for training as nurses would help to address the shortages that we are experiencing. Perhaps we should consider bringing into the profession people who are not as young as those who would prefer to pursue the academic route into nursing. Did your group consider that?

That was a series of important points. James Kennedy, who is director of RCN Scotland and who co-chairs the Scottish partnership forum, was on our group. As you would expect, he gave a large voice to nursing. When I talk about clinicians, I really mean clinicians and the broad spectrum of allied health professionals.

I hate to sound antediluvian, but you and my wife share the same outlook. She trained in the Western infirmary. The expression "too posh to wash" that has emerged down south is resonating. During my training, when I was a junior doctor, I worked with state-enrolled nurses. That highly skilled and knowledgeable group of nurses has been wiped away, but I do not know enough about nursing structures to comment on that. To bring in bright people with degrees has got to be good for us all, but I agree that having a more flexible approach might encourage people who would be put off by the rigours of taking a degree, but who would nonetheless have a great deal to offer. I do not know enough about the situation, but it would seem daft to marginalise or exclude people who could make a significant contribution. From my knowledge of the old days, I find myself agreeing with you, but I hope that I do not get into trouble for knocking nursing colleagues out of their position.

The group obviously did not discuss that issue specifically, but would you be able to explore it in your discussions with the minister?

Yes, I would. I am having similar discussions down south about how we can get people who made a real contribution to the health service, but who left for family reasons or whatever, to come back. The fact that time has moved on in the years that someone has been away is quite a big hurdle to overcome. You can imagine the discussions that we are having. We need to consider introducing some courses that would allow such people to come into the NHS at a certain level. We would then see how that went. Different promotional models could be used. Your suggestion is definitely worth exploring.

Jean Turner had a question about the training of junior doctors.

It was mentioned earlier that there have been difficulties in finding places for the new training of senior house officers. A doctor in my constituency is unable to get a job up here because of that. If we cannot train doctors, we cannot get them in place, which means that many of the procedures relating to getting people into hospital, where they can be well looked after, go by the board. We all know that, in general practice, we can see one patient at home for five in the surgery. The issue is all about trying to get people's competency up to a level at which they will be confident. We do not want people to have confidence without competence. What do you have to say about that?

If there is a bottleneck in relation to training posts, we need to consider that. I do not have enough detailed information to give a specific answer, but if that is an emerging picture that is backed up by evidence, we will need to carry out an exercise to match the number of kids coming through to substantive posts. Training enough health care professionals to do the right job in the right place when we need them to do it involves quite a complicated formulaic exercise.

Another issue that was raised by allied health professionals is the feeling that, because there is a shortage of doctors, work will be dumped on other professionals. Some of them say, "Doctors don't do what we do because they are not trained to do it, but we have to be trained up to do our job and the jobs that doctors used to do."

We have to get a balance in getting more training places for professionals. You agreed with what Janis Hughes said about the need to open out how we train people; perhaps, having apprenticeship training is not a bad way of doing that and of encouraging people.

Yes. However, I did not get a sense that people were being dumped on. I felt that people were hungry for training and information because they felt that they could contribute more. Perhaps I was just lucky, but everyone I met said, "Train us, let us do more and let us work as part of a wider team." They were looking to be upskilled and did not feel that they were being dumped on.

It might be worth reading the letters that the allied health professionals have written to our committee. A lot of people have passion for their job but, if there are too few people doing it—too few nurses in the hospital and in the community, for example—the job does not get done as well as it should. Whatever happens in relation to implementing the report must go side by side with the need to have sufficient trained professionals at all levels and in every area.

I agree.

That leads neatly to Shona Robison's questions on implementation, but before she asks those, I think she might have a specific question on the workforce.

Professor Kerr, your comments about nursing contained a bit of a dilemma. The delivery of your recommendations will require nurses to take on more and more of the work that doctors did in the past, so there could be an argument for the route becoming even more academic. How do you marry the two differing ideas that we have discussed in relation to nursing? I do not necessarily disagree that there has to be a route in that offers people such as health care assistants a qualification in the nursing profession but, in some ways, your report requires the opposite to happen.

I think that it is internally consistent and cohesive. We are saying that there may be a highly trained, interested and well-educated stratum of nurses, from whatever group, who would want to take on additional roles and become nurse consultants, run community casualty units and so on—we have seen good examples of that—and that there are other nurses who will prefer a more traditional role. It will be horses for courses. Such groups are not two tribes that sit comfortably beside each other, but a seamless progression would take place. We require people who function at all levels.

A role has emerged for the upskilled nurse to do the tasks to which you referred and which we mentioned. Equally strongly, we need the basic primary care, which is important for sick folk. We must not neglect our drive for that. We will not suck every nurse up into being nurse consultants who work in community casualty units and so on. Some movement will take place, but it will not be huge. We will want to bring in other people to support the other role.

The issue might be terminology, because I see that as the health care assistant's role.

It could be.

I will move on to implementation, which will be a burning question for many people. It is interesting that the first line of your implementation section is:

"Of course, this will not be easy."

Perhaps the previous discussion of neurosurgery raises some of the difficulties. The last part of your report says that the NHS in Scotland can meet the challenge of change by

"Building a new relationship of partnership and trust with the public aligned around the direction set in this report."

That means that we must be careful with implementation. I would like to hear your views about how we do that.

I will give an example of dangers. If health boards get ahead of themselves as they move forward, does not the danger exist that trust will be broken before it is even established? I am thinking in particular about changes to accident and emergency services. On changes to unscheduled care, your report suggests that

"In order to facilitate access and ensure an appropriate distribution of care across Scotland, all NHS Boards through their Regional Planning Groups should review over the next 12 months the configuration of the unscheduled care networks on a regional basis".

That is not quite the same as consulting on proposals to close A and E services. How should implementation, particularly of changes to such emergency services, be handled so that health boards can draw back a bit? Much damage could be done in the meantime.

That will be the subject of great contention and it is completely relevant to highlight it. All committee members and I have been struck by the way in which health care has often been planned on the basis of a rather irrational, narrow, geographic bit of Scotland—the old health board boundaries and so on. That led to some health board decisions about how we ask patients to move that looked odd when put beside one another. That connects to your original discussion. If we ask patients to move, we should ensure that it is for good reason, is logical and possible and does not involve three trains, two buses and an expensive taxi ride to receive standard care. That was our thinking.

We have discussed the number of health boards, which I was not charged with interfering with. I hope that we have made a case on that. I felt that we needed the people who would undertake the large, difficult task of delivering change and the report—if we assume acceptance by the Executive—to work to break down barriers and to sort out CHPs and all the rest of it.

The regional point relates to tiers of unscheduled care. At the top tiers—the all-singing, all-dancing ones—regional decisions are required, so that we do not end up with two category 3 or 4 accident and emergency units beside each other across a health board boundary. That would not be right, which is why we imposed regional decision making. We will not step back from that recommendation.

I understand that. However, despite the fact that, as you said, we still await the Executive's response on how the report should be taken forward, at least one health board has, on the back of the report, produced a series of proposals to reduce its accident and emergency services. In your view, is that the right way or the wrong way to proceed?

I do not see a problem if the proposals have been discussed regionally.

Is not the problem that your report proposes a national plan or framework that must be agreed at national level? In particular, the Executive needs to say whether or not the plan is a good idea. Is there not a danger that health boards will be perceived to be taking the opportunity to proceed with the actions that they wanted to take anyway, whether or not those actions are taken for good reasons—as may well happen? The danger is that the public trust to which your report refers could be undermined. Surely it would be better to proceed more slowly so that we take the public with us.

Clearly, you have given both a general example and a specific one, but I do not know anything about the specific example to which you refer. At the back of your mind, you clearly have a specific example of an action that has been taken or is being discussed. However, I honestly do not know enough about the issue to be able to say anything useful.

I am thinking specifically of Ayrshire and Arran NHS Board's proposals.

I honestly do not know enough about that situation, as I have been back in England for a while since delivering the report. I would be interested to know how the board proposes to configure services to see whether its proposals make sense in terms of our recommendations. It would be unusual—I might also be a little disappointed—if the board had proceeded with a consultation on a configuration on which it had not had regional discussion with its nearest neighbours.

It is dead important that we maintain public trust, so we must never let that be lost. We got a lot of momentum behind our report, including serious clinical engagement, and I honestly think—and am prepared to be tested on it—that the mood of the folk of Scotland who attended our public events in town halls was behind us. Neither I nor you want that momentum to ebb away, so we agree on that. Therefore, if the proposals made the public feel in some way disfranchised or hoodwinked, that would be just barmy, plain wrong and doolally.

However, the board might be proposing a sensible and thought-through configuration of services that has been regionally discussed. If, having considered our national report, the board has decided in association with its regional partners that it should respond by proposing certain changes, on which it now wants to ask the public what they think, that seems fair enough. However, I do not know enough about the issue to know whether that has happened.

I will allow a small question each from Mike Rumbles and Duncan McNeil.

On implementation, the final paragraph on page 32 of the report states:

"It is true that a relatively small number of people who might have had emergency surgery in one hospital may in the future have to travel a bit further. But the numbers involved are relatively small".

No one would disagree with that language about people possibly having to travel a bit further were it not for the dangers that might arise, as Shona Robison pointed out, when the report is implemented.

The report says that

"the numbers involved are relatively small in comparison"

as if the issue does not matter, but it will matter to those who will need to travel further. My concern is that such a broad-brush approach assumes that, with central planning, we can have a hospital here and a hospital there, to which some individuals might need to travel further, but that will not matter because of the greater good.

Great small question, Mike.

I will stick up for myself a wee bit. I am just not the sort of person who would ever write or say that it does not matter. You are paraphrasing a wee bit.

The report says that the numbers of people affected will be relatively small.

That is a numerical statement. It means that those patients will be in a minority. We know that the majority of work—some 70 per cent—that is currently dealt with in A and E departments could be handled in what we have designated as community casualty units. Only a minority of patients—a third or less than that—need to be admitted for emergency surgery or physician-type care. Let me say out loud that I do not for a moment mean to imply that sick folk do not matter.

I did not say that.

Okay. That is all right.

I was referring to what you said about the number of people being relatively small.

Yes. The figure is small.

There is an implication there.

The group that worked on the matter did the sums and the figure is relatively small, because 70 per cent of the work can be dealt with in community settings. It is a numerical statement.

But it has implications.

I understand the point about travel, and it is really important. I said that it is unacceptable that it should be necessary to take two trains, three buses and an expensive taxi ride to access services. I agree that that issue must be factored into the configuration of services.

I could not have a better cue. I am delighted that Shona Robison raised the issue of accident and emergency services, unplanned care or whatever we describe it as. The issue has generated a lot of interest throughout Scotland.

You have said that it is not logical to have to make two train journeys and take a taxi or whatever. How can we engage people and be honest with people if they do not understand the rules of engagement of the consultation process? What factors will decide whether a community such as my own—I do not want to put you on the spot, but you can generalise—will have a certain level of hospital service? What weighting decides whether a service is level 1, 2, 3 or 4? Is the decisive factor travel, the nature of the community, the population size or the type of people who present as admissions?

I know that the convener will come back to consultation. Unless people understand the rules of engagement, there will be mistrust. We want to know what the rules of engagement are.

That is a very interesting question. I do not have a list of rules that I could give you off pat, but we need them. In this first step of the process, what we did not do was to put pins in a map. We wanted to be broadly descriptive about the tiers of service and what they should be. We were not washing our hands of the matter or stepping back, but we did not state where the services should be situated. We did not, in the usual way, go to a bunker in the Scottish Executive—I had better watch what I say, but one model for conducting such an exercise would be to get a bunch of health professionals together and do the map exercise without taking account of the entirely legitimate and dead logical questions that you pose.

We should flag up the creation of such rules as a piece of work for the Executive to think through to ensure that the decision-making process is transparent and that folk do not feel that services are being moved for arbitrary reasons of shroud waving or however it has been perceived—probably wrongly—in the past. We could come up with a series of items that would allow us to respond to the question that Duncan McNeil has asked, but such a response would currently be off the top of my head. We need to do that piece of work. The point is very interesting.

It is not like Duncan McNeil to be interesting, is it?

That leads on to the questions that I want to ask, and other members might want to come in.

First, I ask you bluntly why there was no mention anywhere in your work of the provision of maternity services, which has been one of the most controversial areas of provision of health care in Scotland in recent years.

When we asked the Executive what items or issues it would like to look at it suggested a few—the ones that I mentioned such as neurosurgery and child health. We did not pick up on maternity services. I thought that you were also going to ask about mental health services.

I could ask about those but, in the context of implementation and consultation, maternity services—along with A and E—have easily been the single most controversial issue in Scottish health provision over the past five years. I find the omission unusual to say the least.

Remember that the report is a 20-year plan. We were charged with trying to find generic, widely applicable solutions. I would argue that the solutions—the ideation—in the report would fit maternity services.

What level of maternity services: 1, 2, 3 or 4?

I said that they would fit, but I do not know enough about it to give a specific answer—I truly do not. We asked the Executive what areas it wanted to focus on, but maternity services was not one of the areas that it proposed.

I bet it was not. The issue of consultation is central and the arguments about maternity services point up the enormous deficiencies in how we consult people.

I want you to address certain issues. In the section headed "Our Key Messages", on page 5 of your report, you make a bold statement about the need to

"Develop options for change with people, not for them, starting from the patient experience and engaging the public early on to develop solutions rather than have them respond to pre-determined plans conceived by the professionals.

If that is done for an area such as maternity services, the public's clear response is not what the health professionals want to hear. Therefore, they take out certain options and present what is left to the public. The public's preferred option is no longer in the refined list of options, so it becomes clear to them that they will not get what they want. That scenario probably applies to consultations on other services as well.

Given the statement in your report about public involvement, how will you turn that situation around, given that in many cases the public's response will not be what you or health professionals want to hear?

In a way, you have answered your own question, which allows me to speak generally about consultation. I agree with your point, but it refers to what happened before, when consultation on services such as maternity services, mental health services or cardiology was binary in form, in that the message was to take it or leave it. Such consultations provided carefully considered options that health professionals had bought into, which were presented in an arbitrary way. We agree with the criticism of that form of consultation and I have blown it away in my report. Consultation on maternity services, for example, must follow the model that you want to promulgate and that we described in the report, which is to work with people to develop a service rather than to impose something on them.

The report blows away the old model that we both agree is wrong and antediluvian. It should be moved aside and replaced with a brighter, more positive way to embrace the future together.

So the model that was used as recently as a year or two ago is antediluvian. However, you have still not explained to me how consultations will genuinely take on board public demands if the demands are for something that the health professionals do not want.

We specifically addressed that problem by saying that we would not impose a predetermined solution on anyone. When we consulted on the report, we did not go to public meetings with bits of paper that stated what was option 1, 2 and 3; we went with a blank sheet. We went to listen to people. I did not try to sell anybody anything at our town hall meetings. We picked up on a model that was used in Forth Valley and which Peter Bates used successfully in Tayside.

Are you referring to one-day conferences and so on?

They went about things in a range of different ways. It is not fair to dismiss their approach. They made an honest effort to engage with citizens, bring their two groups together and try to come to a joint solution. That is what you and I want. The issue is about creating a forum that allows us to do that. The successful models that we would operate would consign the old, duff, arbitrary consultations to the dustbin of the past.

The Tayside consultation took over four years and resulted in precisely what the health board had wanted to do at the start of the process, which caused a great deal of public alienation in the health board area. I am not entirely sure that I would be confident if you thought that that consultation should be a model. I dare say that other members will want to say something about that.

The convener is talking about past consultations. In Aberdeenshire, the five community hospitals with maternity services are all currently under review. The public do not want them to close. We keep on saying to people that they should have the option of having their baby delivered at the hospital in Aberdeen, in the community hospitals or at home. On Friday, I visited Aboyne hospital, which is 30 miles from Aberdeen. People in Braemar have a 120-mile return journey to Aberdeen and the public want local services to remain.

Yesterday, I was at a health board briefing, which was attended by the chief executive. The word "cost" was used three times to us. It is clear to me that the consultation will show overwhelming support for retaining maternity services but, as Roseanna Cunningham said, there seems to be a view that the health professionals will want closure.

I cannot prejudge an issue that I know nothing whatever about, and you would not expect me to do so.

That is happening now.

There is an issue for the Scottish Executive Health Department—and others—which must give advice, help and support to move things forward, but—

I am sorry to interrupt. There is a new era now, but those consultations have ended.

There is the technical matter of waiting for the Executive to respond. I hope that the Executive will adopt the various ideas that we have proposed. In the interregnum, stuff might be going on out there that you feel uncomfortable with, but two sides must be brought together in any consultation. There are two sides in discussions and arguments, and the type of engagement that we have modelled will allow both sides to see and understand the pressures on the other and to come together to reach an approved joint solution.

Convener, I would like to—

There are people waiting to come in on that point.

On a point of order, convener. It was said that maternity services were not covered by the report, but they are discussed on page 204.

I know. The first sentence on that page states:

"The work streams of the National Framework for Service Change do not specifically cover maternity services."

There are two or three paragraphs on maternity services.

I know, but the section begins by saying that maternity services are not covered by the national framework for service change.

There is a whole chapter on them.

It is important to know bed numbers if we want to continue with the idea that we are in a new era. For years, we have been desperate to know the right bed model for Glasgow. As Professor Kerr probably knows, many people lie around on trolleys and cannot get into hospitals. The latest news from a board meeting that took place this morning is that in-patient and day cases over 26 weeks increased by 29 per cent between July and August.

The bed modelling report went out for consultation on 26 July, and people wanted it to be back by 19 September or thereabouts. There has been a holiday period. Professor Kerr wants the faith of the general public to be restored, but it is difficult to restore faith for those who work in the health service. I am talking about the nurses who are desperate to find beds and who shuffle people around and try to shove them out into the community before it is time to do so. Some elderly people think that the onus should be on them to decide whether they are fit to go out into the community, but nothing has changed in the important document that we are discussing. I get the impression that people are scared that there will be centralisation whether or not you have produced a report and that health boards will continue as they want to continue without consulting people whether or not what they do is wrong and ends in a mess.

That would be disappointing and plain wrong. I could not agree more with what you say.

You mentioned beds. A bit of me believes that we in Scotland must use beds better. We have tried to say that we will be able to keep patients out of hospital, look after them better in the community, save beds and use those beds more effectively as a result of modernising and redesigning services. There is an interesting dynamic about beds.

We would really need to have care in the community fixed before we could put people into the community and we would need personnel to look after them.

I agree.

The questions that you are being asked today are nothing compared with some of the questions that you will be asked out there. Perhaps this is a good rehearsal for you. Do you think that the principles of your report should apply to maternity services?

Generally, yes.

A number of things in the report of the expert group on acute maternity services, to which you refer in the section of your report on maternity services, could change. You talk about the role of specialist GPs, such as those who specialise in obstetrics. An awful lot more could be said about that in relation to sustaining maternity services in localities. An opportunity has been missed, in that that section could have been fleshed out a lot more to point the way to how we could develop and sustain local maternity services. As soon as the EGAMS report is mentioned, those who are fighting to retain local maternity services sigh, because it does not provide much hope of there being a different way of thinking. You have said that the principles of your report should take precedence.

I feel manoeuvred. I am not sure about the precedence issue. I think my report should be mapped on to—that would make sense—because there are generic principles that could apply to all bits of health. That is a reasonable statement. I am not sure about the precedence issue; I do not know enough about it.

I think this set of questions has come to a natural end.

I said at the beginning that I was interested in asking Professor Kerr about implementation and people. He works in England and might have more knowledge of this. The BMA is extremely concerned about bringing in private companies to do work, which has a knock-on effect on the training of doctors and other professionals. If, as is being said, the private sector takes the easy stuff, it leaves the difficult stuff for the NHS to do, which means that, no matter how hard we try, we will crumble and end up going to five big centres—

Ask a question, Jean.

What is Professor Kerr's opinion on bringing in the private sector and its knock-on effect on the education of our young doctors and all other health professionals?

I am fairly agnostic about it. I have never practised private medicine and I never will. If the private sector can be brought in sensibly without interfering and it can add capacity, why not bring it in? If it works, why not embrace it? However, it should not get in the way or do any of the negative things that you suggested.

Would you be concerned if it were to be brought in in the long term? Do you see it as a short-term measure?

No. It is about getting things fixed and using any means that we can to do so. I have seen good and bad private sector involvement in England.

I am surprised that you have no feeling one way or the other on that.

I am being pragmatic. Without getting involved in any small political philosophy, if the involvement of the private sector fits, adds capacity, gets people treated quicker and better and meets the needs of the populace without doing harm, why not have it?

Thank you, Professor Kerr. It is not beyond the bounds of possibility that the Health Committee will continue to be in touch with you on a number of these issues. We will give you as much notice as possible of whatever we want to do. I will suspend the meeting for three minutes.

Meeting suspended.

On resuming—