Meeting of the Parliament

Meeting date: Wednesday, September 7, 2016

Official Report 878KB pdf

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Cleft Lip and Palate Surgery (Centralisation)

The final item of business today is a members’ business debate on motion S5M-00565, in the name of Miles Briggs, on opposition to centralisation of cleft lip and palate surgery. The debate will be concluded without any question being put.

Motion debated,

That the Parliament expresses its concern at the decision by NHS board chief executives on 21 June 2016 to approve the recommendation of the National Specialist Services Committee to centralise cleft lip and palate surgery in Glasgow; is aware that cleft lip and palate surgical services are currently provided at both the Royal Hospital for Sick Children, Edinburgh and the Royal Hospital for Children, Glasgow; considers that the Edinburgh team delivers a world class service with high quality care and is aware that the audited outcomes for children following surgery in Edinburgh are extremely high; notes that the Edinburgh unit currently provides care for children living all across eastern Scotland; is aware of concerns among parents and clinicians about the consultation process for this proposed centralisation and that more than 5,700 people have signed an online petition opposing the plans; is further aware that the Cleft Lip and Palate Association (CLAPA) has spoken out about the lack of evidence to show that the existing two-site model is not working; is further aware that the Edinburgh unit is due to host the International Congress on Cleft Lip/Palate and Related Craniofacial Anomalies in 2021, and notes calls, given the level of concern among patients, parents and clinicians, for the Cabinet Secretary for Health and Sport to intervene and pause the centralisation plans to allow further consideration and to ensure that the specialist expertise, knowledge and care that has been built up in Edinburgh is not lost.

17:03  

I thank colleagues from my party and from all the other Opposition parties in Parliament for supporting my motion and allowing this evening’s debate to take place. I welcome constituents and others to the public gallery this evening, including some of east Scotland’s cleft patients and parents. I especially welcome Evonne McLatchie, who has done such a fantastic job in campaigning on the issue and spearheading the online petition, which has now attracted the support of more than 6,000 people across Scotland and which I was pleased to accept this afternoon on behalf of the Parliament.

During the Scottish Parliament election campaign, I met a number of Lothian parents who expressed real concerns at the way in which the consultation on centralising cleft palate surgery in Scotland was being handled. I made a promise that I would support them and take up their cause if elected to Parliament. I have found it heartening and incredibly positive to hear their personal family stories, repeated again and again by parent after parent. They are stories of the excellent treatment and best-quality surgery that their babies and children have received from the Edinburgh sick kids surgery team and of the life-changing and life-defining difference that it has made to so many babies and children across Scotland.

It is not an overstatement to say that the cleft lip and palate surgery that is carried out in Edinburgh by surgeon Felicity Mehendale is world leading, and that the outcomes are some of the very best that any child or parent could ask for. However, those outcomes are down to not just Ms Mehendale but the first-class team that surrounds her: theatre staff, post and pre-op staff and highly skilled cleft nurses, all working closely together.

The audited outcomes for the Edinburgh surgical unit explain why parents are right to have such faith in it. Official information on United Kingdom standards for speech outcomes following surgery to repair cleft palates shows that the results for children treated in Edinburgh are consistently very high, with the vast majority of children having speech within normal range five years after surgery, which means that Edinburgh is beating national targets and is among the top-performing units in the UK.

I am sorry to say that that information was not part of the options appraisal in the official consultation process and was made available only as a result of a freedom of information request, which is a real concern to parents and campaigners. The information should have been made available. The fact that it was not feeds into genuine worries about other aspects of what seems to have been a flawed consultation process that has failed to justify the suggestion that the east of Scotland service is in any way unsustainable and has left clinicians and staff in Edinburgh feeling that their views have been totally ignored. I am sorry to say that there are recurrent instances of a lack of transparency, openness and accountability surrounding the consultation.

We need to recognise that the Edinburgh team does not just enjoy the support of parents and other clinicians across Scotland and the UK, but has an international reputation for its care, research and expertise. Indeed, such is its standing that the Edinburgh unit is due to host the prestigious international congress on cleft lip/palate and related craniofacial anomalies in 2021. Eighteen hundred professionals from more than 70 countries are set to attend the 2017 conference in India and similar numbers will be expected for the Edinburgh conference. How embarrassing will it be for Scotland if Ms Mehendale feels forced to leave the national health service and neither she nor a cleft surgical unit is based in the host city of Edinburgh?

I am concerned about the unintended consequences of closing the Edinburgh surgery unit. At present, St John’s hospital in Livingstone is home to the adult cleft palate care service, which is supported by Ms Mehendale and her team. The impact that the closure of the Edinburgh unit will have on adult services and patients who receive their treatment there has never been outlined. In fact, from my investigations I can only draw the conclusion that that has not been considered or, worse still, has been overlooked.

Many parents have expressed concerns to me about the additional stress and pressures that would be placed on them and their children because of the extra time, travel costs and time off work that would be required to travel to Glasgow. The Scottish Government talks about accessibility in the NHS, but the centralisation plans would make access more difficult for many families in eastern Scotland. It is perhaps also worth noting that it is not long since the Aberdeen service was closed, following which patients and parents have received support through the Edinburgh service.

Taking all those points together—widespread parental and community support for the Edinburgh surgical unit, outstanding audited outcomes, an international reputation, concerns about the consultation process and worries about the accessibility of a single service based in Glasgow—it is hardly any wonder that the Cleft Lip and Palate Association and many others are struggling to understand the rationale behind the proposed centralisation in Glasgow and believe that the case for changing the current two-site model simply has not been made.

I want to be clear that this is not, and must not become, an Edinburgh versus Glasgow issue. Rather, it is about supporting a two-site model that works, is sustainable and can be made even more effective through the collaborative working of surgeons across both sites. The twin-centre model works successfully elsewhere in the UK in many locations and is about maintaining and preserving an international centre of excellence that has built up and delivered such important specialist expertise, knowledge and care.

Sometimes Governments make bad decisions. I have no doubt at all that the closure of the cleft lip and palate surgery unit at Edinburgh’s Royal hospital for sick children and the potential loss to our NHS of an internationally recognised specialist surgeon would be a backwards step. I hope that by bringing this debate to Parliament I have given Scottish ministers a chance to pause and reflect, and to prevent that from happening.

I end by urging the Scottish Government to listen to the very clear views of parents and clinicians and ask that it does not approve the centralisation plans but rather supports the retention of what is a successful and valuable two-site model. That would be in the best interests of parents, clinicians and, crucially, babies and children born in Scotland who need that specialist surgery and care. [Applause.]

I say to the people in the public gallery that you are very welcome. I understand your strength of feeling and that you are here to support the motion, but I must ask you to refrain from clapping from now on. Perhaps at the end of the debate we can allow you to express your support for members’ speeches. Thank you.

17:10  

I appreciate the opportunity to take part in this debate on the centralisation of cleft lip and palate surgery, and I thank Miles Briggs for bringing this important issue to the Parliament. I have an interest in the matter, because I have constituents who will be directly affected by the proposal to move the service.

The minister will be aware that the current provision of specialist cleft surgical services at the Royal hospital for sick children in Edinburgh is exemplary. The recent consultation and report, which found that the best decision would be to centralise services in NHS Greater Glasgow and Clyde, does not take fully into consideration the impact that the change would have on families who rely on the service in the east of Scotland.

We must also take into consideration that the service that is provided in Edinburgh is led by a pioneering and world-class surgeon, whose record of excellence speaks for itself. In Edinburgh, a multidisciplinary team works side by side with patients and the surgeon to ensure that everything runs smoothly and progress is made after every surgical event. Patients know that they can rely on the hospital to get the job done. Those are all valid reasons why the Government should consider ensuring that support services are retained in Edinburgh.

I can say with confidence that my constituents who will be directly affected by a move are dismayed that the service will not be provided as close to them as they need it to be. I have a great deal of sympathy for them in opposing the service’s move to Greater Glasgow and Clyde, and I ask that centralisation plans be paused, to allow for further consideration and to ensure that the specialist expertise, knowledge and care that have been built up in Edinburgh are not lost.

I understand that change can be a good thing and that there are financial pressures on NHS boards throughout the country. It is my opinion that, in this instance, having a surgical team in a single area bodes well for the provision of services in the long term. However, the removal of services from Edinburgh presents a geographical deficit and the real possibility that world-class surgeons will not be able to relocate.

I have been in touch with my constituent for some time about her concerns over the proposal, and I have raised the issue with the cabinet secretary on more than one occasion. It is understandable that my constituent is worried about the impact that the move will have on her family in the short term. Patients who must move from one area to another sometimes feel as if they have to start again. The moving of clinical notes from one health board area to another might give staff in the new area insight into the patient and their history, but that does not mean that staff really know the patient. All the relationships that have been built up, sometimes over many years, potentially have to be rebuilt from the ground up.

If I put myself in the position of a young child who is facing surgery to enable them to have a better quality of life, I can see that surgery must be a very daunting prospect. The upheaval of having to be treated in an unfamiliar hospital must be an added and perhaps unnecessary stress.

I have been contacted by retired consultant plastic surgeon John Howard Stevenson. He was adviser to the chief medical officer on cleft surgical services, and was clinical director of specialist services in NHS Tayside, which included the disciplines in reconstructive plastic surgery and dentistry that are crucial to successful outcomes in cleft lip and palate reconstruction. During his period in office, services were centralised in Edinburgh and Miss Felicity Mehendale was appointed consultant with responsibility for those patients.

Mr Stevenson wrote to me to say that the clinical evidence supports the retention of services in Edinburgh and that the service that that world-class surgeon has built up in Edinburgh is not only one of the best in the United Kingdom but recognised as being of an international standard. He wrote, of Miss Mehendale:

“Since her appointment, she has developed a service for patients with cleft lip and palate in Edinburgh serving the East of Scotland which has delivered the highest quality of service as evidenced by the internationally agreed outcome standards within this discipline.

These results ... clearly demonstrate consistently higher results than anywhere else in Scotland and on a par with the best Internationally; to achieve these, it is essential to build up a close team involving specialties such as speech therapy, and Felicity has been very successful in building up and maintaining such a team; further, patients and their families have the highest regard for her and her team.

To relocate cleft services from Edinburgh, centralising in Glasgow, will undermine an outstanding service, and goes against the overwhelming clinical evidence—which, surely, must always be the defining factor in deciding where a service should be located—which unequivocally confirms Edinburgh as the base from which patients undergoing cleft lip and palate repair in Scotland can expect the best outcomes.”

Presiding Officer, I realise that I am out of time, although I had more to say.

Yes, but I think that we have heard enough, interesting though it is, Mr MacDonald.

I urge the cabinet secretary to seriously consider the option of retaining this world-class service in Edinburgh.

17:15  

I thank Miles Briggs for securing this important members’ business debate. The proposal to end the surgical service at the sick kids hospital in Edinburgh and to centralise the cleft lip and palate service in Glasgow is set against a backdrop of huge financial pressures on our NHS. Boards across Scotland are having to find huge amounts of money and are finding black holes in their budgets. NHS Lothian this year has a deficit of £84 million, which means beds closed, posts cut and legally set targets missed. I believe that the centralisation of services in that way is directly linked to budget decisions, although they will be dressed up and presented as service improvements and redesign.

There will be much more to come. We have just fended off the plans to centralise children’s services, and now we are on to the next stage of the process. I come to that conclusion because there seems to be no other credible explanation for the move that we are debating today. In fact, the decision has provoked complete bemusement among many stakeholders, patient groups and doctors. People are, to be frank, at a loss to understand why the decision has been made, and some serious questions hang over it. The outcomes in Edinburgh appear to be better. If the whole issue in healthcare at the moment is outcomes, why is a service with excellent outcomes being closed down and centralised? Perhaps the minister can confirm whether the better outcomes in Edinburgh were taken into account when the decision was made.

What about the excellent continuity of care that is to be found in other NHS regions including Tayside, Grampian and Highland? Relationships that have been built up over the past 10 years will be compromised. Why is a service that has developed those excellent relationships across the east of the country not being nurtured and protected?

Let me make it clear that the decision is about surgery. Locally provided support—whether that is orthodontics or dentistry—will continue to be provided locally.

I may come back to that. What evidence base is being used to justify ending the twin-site surgery centres when we see twin sites working well in other parts of the UK? Has that approach not worked in Scotland? If it has not, can the minister share the evidence that tells us that the approach has not worked? That is one of the many concerns that have been highlighted.

Given the evidence and the justified criticisms by parents and campaigners, there appears to be only one explanation for the decision. Once again, it boils down to cuts to public services and our NHS that are dressed up and camouflaged as service redesign and improvement. The Scottish Government makes its own choices, and many of those are bad choices that are not serving the people of Scotland well. The decision is simply the latest in a long line of centralising decisions that have ridden roughshod over the wishes of patients, staff and campaigners.

It is about time that the Government started to use the powers of the Scottish Parliament to ensure that adequate funding is provided to our NHS and other public services. We can do it, but we need the political will. After all, these are services that the public need and services that, I believe, civilise us as a society. There is no doubt in my mind that the cleft lip and palate service in Edinburgh is providing a vital service that we should value and protect. The cabinet secretary should intervene, reconsider and then reverse the decision.

A decade ago, the SNP cynically exploited the NHS for electoral gain. Whatever happened to the mantra, “Keep healthcare local”? For the minister, the cabinet secretary and the Government, the sky is dark with chickens coming home to roost. The chief medical officer for Scotland talks about the concept of realistic medicine—that is the reality of the NHS in Scotland in 2016.

17:20  

I congratulate Miles Briggs on securing a debate on young children who need cleft surgery—an important issue for them and their families—both in Lothian and around the country.

I thank the Royal College of Surgeons for its views and guidance. I understand that it supports the principle of centralisation where there are clear clinical benefits for it: centralisation can help staff to specialise further and it can support high clinical standards. However, in the short time that I have today, I want to voice the principal concerns that have been raised with me by constituents and professionals about the decision to centralise all cleft surgery. The concerns are about how the review of surgery arrangements has been conducted, about the quality of the consultation and about the impact on cleft care in Lothian and around Scotland.

I have some doubts that the premise on which the review of services has been conducted is reasonable. It was launched because the current model of delivering a single service over two sites has not, it is claimed, resulted in a properly integrated service. However, instead of considering why that has not happened and what can be done to improve integration, the cleft management board proceeded straight to considering new options. Indeed, some members of the panel that appraised the options in October last year queried whether it was worth evaluating the status quo at all, so I am concerned that it was not given a fair hearing.

The lack of detail on why the current arrangement is not working was criticised during the options appraisal in a large number of submissions by parents. Clinicians, parents and the Cleft Lip and Palate Association—the charity that represents patients with clefts and their families—have repeatedly asked for information about what aspects of the current arrangements were not working, but feel that a full answer has never been provided. They have publicly stated that they have not been provided with sufficient information to make an informed evidence-based decision on whether to support the proposals.

According to surgeon Jon Clarke, twin-site cleft services operate well across the UK—for example, in Liverpool and Manchester. Consideration of why integration has been more successful elsewhere than it has in Glasgow and Edinburgh does not appear to have been a significant part of the appraisal. Until we are certain exactly where problems in delivering the existing service lie, and what further support could improve the situation, can we be sure that moving to a single-site service is the most appropriate solution? I suggest that we cannot.

The appraisal document makes reference to the significant differences in the outcomes between the Glasgow and Edinburgh surgery sites, but were those differences fully taken into account? That concern has been raised by a number of surgeons who were formerly involved in cleft care. Edinburgh’s track record in terms of the percentage of children having normal speech after primary surgery far exceeds that of Glasgow. According to Jon Hammond, who is a retired consultant orthodontist, the number of children who were treated in Glasgow who fail to achieve the normal-speech benchmark is 60 children in every 100 who undergo palatal repair surgery, which is a failure rate almost double that in the east. While I am by no means suggesting that that is outwith the normal range of success for cleft surgery, there are nonetheless clear differences on a number of measures of success, and we should seek to understand why.

It is worth noting that representatives of families scored the current arrangement more highly than they scored either centralisation option during the options appraisal, but it is not clear how that figured in the final decision.

In the light of the national specialist service committee’s observation that there were shortcomings in the consultation process, I urge the minister to look again at the proposals, with particular reference to the excellent surgical outcomes that have been achieved in Edinburgh and the strong views of patients and staff. Given the concerns of patients and staff that are cited in the consultation report, and the concerns about the overall consultation process that have been expressed by the national specialist service committee, it is absolutely unclear that a single-site service based in Glasgow will lead to better clinical outcomes for current patients. Also, given that twin-site cleft services operate very well elsewhere, further steps must be taken to look at supporting the current service in Edinburgh in order to assure continuity of care for patients and families in Lothian and the east of Scotland.

17:25  

I am delighted to support the motion lodged by my colleague Miles Briggs on this important issue. I, too, echo some of the remarks on the issue that have been raised by colleagues across the chamber, who made very compelling arguments in favour of the retention of the services.

It is a very emotive subject, as can be seen from the many thousands of submissions made by concerned parents and campaigners, some of whom are sitting behind me in the public gallery. One of my first meetings as an MSP following the May election was with such campaigners. Indeed, my first correspondence with the Cabinet Secretary for Health and Sport was about this very service. I completely empathise with the campaigners’ position.

I want to use this opportunity to defend the cleft service in Edinburgh. I have a personal perspective to offer, too: a niece and nephew of mine were born with cleft palates, and they have both been through the Edinburgh service with great success.

The cleft care Scotland network noted that the centre in Edinburgh performs nearly half of Scotland’s cleft surgical procedures each year, and more than half of those are for patients who reside in the Lothians region. In that sense, it is easy to see this simply as a local issue. However, it is important to realise that the reach of the service goes far beyond the city, the Lothians region and the central belt.

I represent the Highlands and Islands. According to the NHS’s consultation document on the proposed change, between 5 and 10 per cent of the total number of Scottish patients come from my region. As a result, I have been contacted by patients and families who come from my region—a long way from Edinburgh—but who have used the city centre because it is a world-renowned service and possesses one of the world’s leading cleft surgeons, Dr Felicity Mehendale.

We should listen to some of the medical experts. Isabel McCallum, the former clinical director of the Edinburgh Royal hospital for sick children, has questioned the clarity of the proposals, saying that it is “not at all clear” how patients would benefit from a centralised service and how the clinical service would be enhanced.

Maureen Harrison, the former chief executive officer of the Sick Kids Friends Foundation, also stated that she did not believe that

“centralisation ... would be the best way forward for the children in the east of Scotland”.

It is clear from the 6,000-plus supporters who have signed a petition that was set up to oppose the centralisation of the service that many of them have not just benefited from the existence of two cleft centres in Scotland, but believe in the retention of the two centres. It is also clear that there is support across this chamber for both centres to remain. I was very grateful to hear Angus MacDonald’s contribution, because it is disappointing that no Scottish National Party members—not even Lothians SNP MSPs—signed Miles Briggs’s motion.

The evidence that I have seen and heard from campaigners shows the process to be rushed and lacking any consideration for the voices of the people who have benefited from the cleft surgery service in Edinburgh. Former health professionals have questioned the proposals and thousands of people have added their voices to the debate. There is a clear and compelling argument to retain this important service, and accordingly I support the motion today.

17:28  

Everyone here shares the same desire: we want to ensure that cleft surgery is safe and consistently able to deliver good patient outcomes.

Miles Briggs was right to point out that the work that our professionals do creates a life-defining difference in children’s and families’ lives.

I am well aware of the strength of feeling from those who oppose the recommendation to consolidate cleft surgery in Glasgow. I recognise they believe that they are raising real concerns about the proposal. I therefore welcome tonight’s debate, and the constructive contributions from Angus MacDonald, Alison Johnstone and Donald Cameron. I particularly want to thank Donald Cameron for his personal reflections on the debate.

Tonight’s debate presents an opportunity to help inform our shared understanding of the issues involved and to clear up some of the issues that others have raised. I also want to place on record my thanks to Evonne McLatchie, whom I met earlier and who shares with passion and dedication our ambition for improvements. I thank her for her time and for articulating her concerns and the concerns of the others who I know are in the chamber this evening.

The national clinical strategy is our blueprint for health and social care over the next 15 years, and it is one of the key drivers that will help us deliver transformational change across our NHS. The strategy makes it clear that if we are to provide the best outcomes for patients, services need to be planned on a population-based once-for-Scotland basis. As a result, we must look to increase collaborative working across NHSScotland to deliver services that will benefit all patients, no matter where they live.

With the delivery of an NHS that is fit for the future, patients should rightly expect our health services to be safe and sustainable. “Sustainable” means that services must be consistently able to deliver high-quality treatment and care. The recommendation to consolidate cleft surgery—it is important to remind ourselves that this is only a recommendation—has been made with the national clinical strategy’s ethos in mind. Patients should expect no less. I should also say, in response to Neil Findlay, that this has nothing to do with costs; it is all about ensuring high standards of services, and the proposals that have been brought forward are cost neutral.

Experience tells us that patients and families want the best treatment available and are willing to travel to access the excellent care that our highly specialist services provide. However, in delivering transformational NHS change, there will be those who oppose it and who have the genuinely held concerns that members have articulated this evening.

Maintaining two centres remains an option but, as it stands, the two-centre model raises questions of sustainability, particularly with a single surgeon operating alone in Edinburgh. Services need to be resilient to unexpected absences to ensure that patients receive their surgery when they need it.

I know that some families are worried a surgeon might leave if the recommendation is approved. Let me be absolutely clear: we do not want that to happen, and we will do what we can to keep all the surgeons working here in Scotland. However, we must design a national cleft surgery service that is resilient to such risks, and we must plan and deliver services that will achieve the best outcomes for all of Scotland’s patients. That is why one option is a collaborative three-surgeon team. It has been suggested that a single team of surgeons will be better able to share the workload, to learn from each other and to improve patient outcomes in a collaborative manner for the benefit of all cleft patients across Scotland.

As we have heard this evening from Miles Briggs, Angus MacDonald and others who have contributed to the debate, there are alternative options, and we are seriously considering each and every one of them. Whichever service model is adopted, we very much hope to retain the specialist knowledge that we have here in Scotland and build a collaborative three-surgeon team that works well together. Work is under way to actively seek to support the Glasgow and Edinburgh surgeons to make that happen, and the 2021 conference that I think Miles Briggs referred to will provide an opportunity to showcase good results across the whole of Scotland instead of concentrating just on one area.

Another issue that has been highlighted is differences in speech outcomes, and work is on-going to look at those data in more detail to try to understand what they tell us. We shall consider the findings alongside all of the information that will guide our decision making.

Although the online petition clearly indicates the strength of opposition to the proposal from the east, it is important to highlight its suggestion of a reduction in local cleft services if the recommendation is approved. In response to that and Miles Briggs’s concerns about the impact on other related services, I have been given a categoric assurance that the proposed changes relate only to cleft surgery. Orthodontics, speech therapy, dental services and support from specialist nurses will continue to be delivered locally and, in addition, specialist outreach clinics will be retained. There is a clear commitment to ensuring that what can be done locally will be done locally.

Is the minister aware of the potential impact that this will have on services at St John’s in Livingston and on the adult patients who are seen at that hospital by the Edinburgh team? What can she say about that and the potential future of that service?

We are clear that the proposals that have come forward to us are about the surgery only. We want to ensure that people can access the local support that they need where they need it, close to their home, and continue to get that much-needed support, which is essential for the smooth recovery process after surgery.

There has also been much criticism from the east about the options appraisal process and the public consultation. It is clear that there are lessons for the NHS to learn and actively reflect on. I am vexed to have heard from Evonne McLatchie about her concerns, which she raised with us at this afternoon’s meeting. The Scottish Health Council has indicated that it is broadly content with the consultation, but nevertheless we must take heed of the concerns about the process that have been raised.

I very much hope that members will recognise that the Scottish Government is listening. The Cabinet Secretary for Health and Sport has met the Edinburgh surgeon as well as the petitioner to hear their concerns first hand. Ms Robison also intends to visit both the Edinburgh and Glasgow teams to hear their views. We have received a steady flow of correspondence, and we are aware of all the arguments against consolidation. I am pleased that this debate has presented a further opportunity to ensure that people’s voices are heard.

Will the minister give way?

I am sorry; I am in my final 10 seconds.

You can give way if you wish to, minister. We have some time in hand.

We have plenty time.

Mr Findlay, that is for me to say, not you.

I do not have my card in my console, and I cannot get it out of the one next to me.

Mr Carlaw, you have to be better prepared than that.

It is stuck. My apologies, Presiding Officer.

I was interested to hear that Ms Robison will visit both centres. Will the minister ask Ms Robison whether she would be prepared to come to Parliament to make a statement on the basis of the evidence that she has so that, when she is fully briefed on the issue at a later stage, there will be an opportunity for members to question her on it?

What I will guarantee is that there will always be a mechanism to ensure that Parliament is kept up to date with the procedures to take the decision and that Mr Carlaw, Miles Briggs and many members who have contributed to the debate will get a chance to know the timeline for the decision making. I reiterate that Ms Robison is carefully considering all the views and opinions, and she wants to ensure that she engages with the two teams on which the proposals concentrate.

Although it is clear that there are differences of opinion on what is best for Scotland’s cleft patients, all views have been and continue to be taken into account. No decision has been made. The decision whether or not to accept the recommendation rests with ministers.

Again, I thank the parents and families who are here. I assure them that we will give every consideration to everyone’s views and will make a decision in due course.

I pay tribute to Miles Briggs for bringing the debate to the Parliament and to the parents who have attended the debate, and I thank members who have made positive and constructive contributions. Please continue to engage in the dialogue as we work through the proposals that are presented to ministers.

Meeting closed at 17:37.