National Health Service
The debate this morning is on motion S1M-1324, in the name of Susan Deacon, on NHS governance and accountability, and an amendment to that motion.
I am glad that we have the opportunity to have this important debate in the Parliament this morning.
The national health service is our biggest and most important public service. Its founding principles hold good today, as they did when it was created more than 50 years ago. The challenge that we now face is to build on the foundations of the past, while providing a service that is fit for the future. The Executive has given an unequivocal commitment to work to modernise and improve the NHS. We have made it clear that that requires both investment and reform, and we have taken action on both fronts.
The modernisation of the NHS is a complex task, but one that we have tackled with vigour and determination. We have done so in partnership with those who work in the service. Next month the Scottish health plan will be published. It will represent the culmination of more than a year's work and will set out the progress that has been made to date, as well as our plans for investment and reform in the future.
In previous debates in this chamber and in discussions with the service, I have made it clear that improving governance and accountability in the NHS in Scotland is a core part of our agenda for modernising the NHS. In the raft of discussions, consultations and research that we have undertaken over the months, issues of governance and accountability have been to the fore.
I have been struck by the extent to which some of the problems that we have identified in the NHS, while manifesting themselves in a poor patient experience, find their roots in flawed decision-making processes, bureaucracy and fractured accountability. There is a clear appetite, and a clear need, for change. I am determined that that should be addressed.
I hope that today's debate will achieve three objectives. First, I want to provide my perspective—based on feedback from staff, patients, managers and others—on the weaknesses and limitations of the current systems of governance and accountability in the NHS in Scotland. The second objective is to outline the Executive's key policy objectives and our thinking on how improvements can be delivered in both the short and the longer term. The third objective is to provide MSPs with an opportunity to express their views on the issue, in advance of the Executive finalising its plans for inclusion in the Scottish health plan.
Grand notions of governance and accountability may seem far removed from the day-to-day issues that affect patients, but they are not; I do not believe that there is an MSP in this chamber who has not discovered that in the course of his or her own work. Issues of concern include: the complexity of the system; the ambiguity of where responsibilities lie; a lack of clarity about who is accountable for what and to whom; and competing and conflicting priorities in different parts of the system. Those practical issues impact adversely on patients and constrain the ability of NHS staff to get on with their jobs. There is growing frustration with the existing arrangements and a real appetite for change. However, there is also a concern, which I share, that any change should be practical, measured and done for the right reason—to improve patient care.
Complex issues such as those do not readily lend themselves to a 20-minute speech. For that reason, I propose to stick to general principles and our policy objectives, but I assure members that detailed proposals for change will be set out in the Scottish health plan and informed by today's debate.
Before I look to the future, I will look briefly at the past; doing that is essential to understanding the issues and problems that we face today. Since its creation in 1948, the NHS has been governed and managed in a variety of different ways. Perhaps the most significant change in recent history was the introduction of the internal market in the late 1980s and early 1990s. The NHS internal market was, by any measure, a hugely flawed exercise. It has done lasting damage to a major national institution. I can say frankly and honestly that in almost 18 months as Minister for Health and Community Care, I have met few who mourn its passing, with perhaps a few exceptions in the Conservative party.
The internal market was the product of right-wing dogma and a flawed belief that the way to improve public services was to develop quasi-commercial practices rather than to build on public service values. The Tories sought to run the health service as a collection of small private businesses rather than as the national public service that it is. The internal market led to fragmentation and division. Millions of pounds were squandered on the bureaucracy of internal contracting mechanisms. Local health systems were broken up into purchasers and providers. Vast amounts of energy and resource were poured into the massive opt-out exercise to create NHS trusts in the early 1990s.
The Labour Government that was elected in 1997 set about, as one of its earliest priorities, dismantling the NHS internal market. The contracting mechanisms were stopped. The inequity of the two-tier system of general practice fundholding was ended. The number of NHS trusts was halved and resources were freed up for patient care. The "Designed to Care" white paper, which was published in 1997, set out a new vision for the NHS, based on partnership, and put in train a series of measures to again join up the system and put patients at its core. The Health Act 1999, enacted in June last year, enshrined in statute many of those changes.
A year on, however, it is clear to me that much more still needs to be done to deliver an NHS that is based on partnership and to ensure that the NHS in Scotland is fully restored as a truly national public service. I have said it before, and I shall say it again: too many of the systems, attitudes and behaviours of the internal market persist. If we are to provide a modern, patient-centred NHS, the last vestiges of the internal market must go.
The NHS trusts deliver services, but what use are the health boards? How does the minister envisage the future role of the health boards, given what she has just said?
There are many different views on the structure of the NHS, and I shall comment later on the issue that Andrew Welsh has raised.
Since taking up office, I have given that message about the internal market loudly and clearly to the NHS in Scotland. I am pleased that many local NHS leaders have responded positively and practically. They have worked to break down barriers and refocus on patient care, to reduce bureaucracy and to put long-term improvements in quality before the short-termism of the trust balance sheet. I am pleased also that many staff in the NHS have grasped with enthusiasm the opportunity to re-establish public service values and to work within the new culture of partnership that the Government has introduced.
However, change has been too slow. In too many parts of the country, there are still turf wars between health boards and trusts. In too many parts of the service, planning systems and purchasing mechanisms do not promote partnership and collaboration. There is still too much focus on institutions and not enough shared commitment to improving health and health services. There is still too much bureaucracy and too little public accountability. Decision making is slow and often remote. Patients, staff and local communities all too often feel shut out from decisions that affect them, and, too often, additional investment trickles through the system and its impact is diluted as a result.
In saying that, however, I am firmly of the view that major structural upheaval at this time is not the answer. Those who are involved in the delivery of front-line patient care need stability, not disruption. They also need greater streamlining and clarity of decision making. I believe that that balance can be struck. There are currently 15 health boards and 28 NHS trusts throughout Scotland. The pattern within each health board varies across the country. Each organisation has its own board, comprising both executive and non-executive members. Although many people would argue—with some justification—that the current structure is not optimal, the reality is that no structure will ever be perfect. Every structure evolves and develops.
There is a need to consider carefully, over time, what a post-market, post-devolution NHS in Scotland should look like. There is also a need to take firm action in the immediate term. Redrawing the map of the NHS in Scotland is not the priority—rewiring the system is. A change in culture, rather than a change in structure, must be our immediate priority.
It is not only possible, but essential, in the short term to retain stability in the structure of local NHS bodies as employers and providers of services, while making significant changes at the top of those organisations to improve decision making and increase accountability. The previous reorganisation of the NHS in Scotland achieved a degree of integration and greatly reduced the number of local NHS bodies. Changes to boardroom structures also saw chairs of health boards and trusts in each health board area coming together round the same table for the first time. We can and must build on that, but we need to do more still.
The local decision-making structures of the NHS are still too complex, too fragmented and over-layered. Each board and trust is monitored and held to account separately, and has separate plans and planning mechanisms. Where effective collaboration takes place, it is often in spite of, rather than because of, the system. We must ensure that, in each health board area, a whole-system approach is developed. Different service providers should have a shared responsibility for improving the health of their local populations and delivering the health care that those populations require. Decision makers in each health board area should come together to address the health needs of their local populations and to develop an agreed plan for the development of health services in that area.
Improvements to the existing planning processes of health improvement programmes and trust implementation plans are necessary. They vary in quality and focus, and in many cases the process of producing HIPs and TIPs has become self-serving.
In the Scottish health plan, we will set out our detailed proposals for change. Our proposals will reflect the views of a wide range of individuals and organisations, and will also act upon concerns that have been raised frequently in this chamber and consistently by the Health and Community Care Committee. We will aim to provide a more integrated system of decision making in the NHS that will bring practical improvements in service delivery and the patient experience. Our plans will also include more effective ways for patients and communities to influence the NHS at local level.
We will seek to streamline and rationalise the existing decision-making structures, reduce complexity and improve accountability. Furthermore, we will seek to facilitate better, closer working relationships between local NHS bodies and their partner organisations, in particular the local authorities. We recognise that that will be achieved more readily where there is coterminosity of boundaries, but we believe that improvements can be made in all parts of the country.
Our Scottish health plan will also set out a detailed timetable and arrangements for delivering change. However, I can be clear that at this stage we are talking months, not years. In developing changes, we will work closely with local decision makers in each health board area. Although we recognise that greater integration of decision making will be achieved more readily in some areas than in others and that no one size will fit all, the direction of travel will be the same right across Scotland.
Alongside those changes, we will introduce our proposals for a new performance management system for the NHS in Scotland. Our approach will be to assess the whole system in each health board area rather than its component parts. Our aim is to achieve a better balance between local and national decision making and a more integrated approach to planning and performance management.
Changes must also be made at a national level, and we have begun that process. The Scottish Executive health department has recently undergone a major reorganisation. The previous divide between public health policy and the NHS management executive has been replaced by a new integrated health department. Performance management processes are being reviewed and a more joined-up approach to policy development is taking place. Trevor Jones, former chief executive of Lothian Health, has in the past week taken up post in the new combined role of head of the health department and chief executive of the NHS in Scotland. I look forward to working with him in further developing those new arrangements in the months and years to come.
An important part of our work will be to make clear and explicit the roles and responsibilities of all parts of the health system, both locally and nationally. That will include a statement of the role of the health department in setting the strategic policy agenda while empowering local health systems to take responsibility for local decisions in response to local needs.
We will strengthen and clarify accountability mechanisms throughout the system, both upward to ministers and then to this Parliament, and—crucially—outward to local communities. If hard choices need to be taken locally, they must be informed by the views of local people, staff and elected representatives. It is striking that, despite the fact that 94 per cent of people who were questioned in a recent public attitude survey commissioned by the Scottish Executive expressed a desire to influence decisions about their NHS, only 38 per cent felt that they had that opportunity. That situation must change.
Increasingly, health and health service issues need to be viewed in the wider context of developing community plans. That calls for a new relationship between the NHS and local government. Although the NHS should not seek to replicate or replace the role of democratically elected bodies, it needs to recognise and respond to their legitimate concerns. We will continue to take steps to remove unnecessary boundaries and barriers that create needless bureaucracy and inhibit the development of seamless patient care.
Earlier in her speech, the minister said that there was too much focus on trust balance sheets. Now she has said that although she will empower the community, the difficulty is that bureaucracy often gets in the way. Is she suggesting that the funding system for trusts will be changed and that, if empowered local communities make their own decisions, the fund flows will automatically follow?
Is the minister saying that the debts that some trusts have accumulated in the past two years will be wiped out? It would be helpful if the minister could be clear about that before we consider the plan. While she is at it, will she tell us what she is going to do about her decision-making process?
I give an assurance that funding flows have been very much on our minds and will be dealt with in some detail in the health plan. One of the problems with the old internal market system was that it tended to know the price of everything and the value of very little. We want to change that. At a time when record additional investment is going into the NHS in Scotland, it is striking that funding often gets stuck in the system and caught up in debates between different providers of care. We cannot afford for that to happen. However, examining how funds flow is only one part of improving the process. It is also crucial to ensure that the NHS takes decisions that reflect the needs of local communities and is accountable to local communities.
In taking forward that work, we seek to re-establish the identity of the NHS as a national health service—a public service—rather than a loose confederation of independent institutions. Too much of the symbolism of the internal market remains, which confuses the public and alienates staff. The public believe that their care is provided by a national health service and staff take pride in the fact that they work for the NHS—all our feedback and research confirms that. We need to make that more explicit throughout the system.
NHS trusts are established under primary legislation. They have considerable local operational autonomy, which is important to the design and delivery of effective services that are responsive to local needs. However, trusts do not, or at least should not, exist as self-serving entities. They are part of a national health service and the public expect them to behave accordingly. I do, too.
The Scottish health plan will provide us with an opportunity to address the main concerns about governance and accountability without unnecessary and unwelcome structural upheaval, but I recognise that there will continue to be issues about the number of different health bodies relative to the size of Scotland. I know that there are many strongly held views on that issue in this chamber.
I recognise that in many places desirable progress towards integration and the development of a partnership approach has taken place. I recognise also, however, that such development is often inhibited by the lack of coterminosity between health and local authority boundaries. In the longer term, we need to consider those and many other wider issues, but any major reorganisation of the NHS in Scotland would need to be the subject of thorough and widespread consultation and may also require significant legislative change that, in itself, would take time. Reorganisation would, therefore, by necessity take years rather than months to achieve.
I have already indicated the importance that I attribute to making significant improvements within existing structures and statutes, but I acknowledge readily the need for a longer-term examination of the wider issues. The Scottish health plan will also, therefore, set out how we intend to take forward that important longer-term piece of work.
I am acutely aware of the understandable fears and anxieties that may be raised by the signalling of any further change in the NHS. Let me provide the reassurance that I know many will seek. The changes that we propose will consolidate, streamline and improve decision making. They will aim to improve, not disrupt, patient care. Front-line staff should be assured that the changes should enable them to get on with their jobs more effectively. Indeed, I believe that those staff have much to gain from what we will propose.
I want also to send a clear message to the people who sit in the local boardrooms of the NHS, many of whom give their time and energy for limited reward, through their commitment to public service. The changes that I want to make are about supporting the design and delivery of modern, patient-centred services. They will provide the opportunity to improve decision making and, in turn, to improve patient care. They will remove much of the bureaucracy and many of the delays that currently annoy and frustrate. As a result, I believe that they should be broadly welcomed. Those who have not responded to the messages from Government and Parliament about the need for greater accountability and a partnership approach in the NHS equally should be clear that they can no longer opt out.
Our national health service should be just that—a national service, a public service, a people's service. Let us today renew our determination to achieve that.
I move,
That the Parliament notes that improving governance and accountability arrangements is a core element of the work underway on NHS modernisation and calls on the Scottish Executive to ensure that meaningful and practical proposals for change are set out in the forthcoming Scottish Health Plan.
I welcome the new deputy minister to his post, if for no other reason than the fact that his appointment means that Shona Robison and I are no longer the new kids on the health block. I can assure the chamber that that is welcome.
The minister has raised some important issues, to which I will return later. It is fair to say, however, that a member of the public would not have anticipated the raising of those important issues on a casual reading of the motion, which asks us to call on the Scottish Executive to ensure that the Scottish health plan sets out "meaningful and practical proposals". As colleagues will be aware, I am not one to praise the Executive where praise is not due, but even I hoped that it would be capable of ensuring that without the compulsion of a parliamentary vote.
That brings me to the first, although tangential, question that I want to raise with the minister: why are we having this debate today? In asking that, I am not suggesting that the content of the debate is unimportant. On the contrary, I think that the minister has touched on some fundamental issues and I will talk about them in a moment. However, the reason for the timing of the debate is not immediately obvious. The issues covered by the minister today will be covered in greater detail in the Scottish health plan, which was supposed to be published at the end of this month. I understand that it will now be published in December, for reasons that are not immediately obvious. Even with that delayed time scale, we will have the publication of the health plan in just over a month.
I know that the plan is intended to be a living, growing, evolving template for change and I welcome that. However, given that it will represent the most comprehensive statement of the Executive's health policy since "Designed to Care", it would have been better to discuss the proposals that the minister has talked about today in the context of the whole plan rather than in isolation.
The minister says that the purpose of today's debate is to give members the opportunity to influence the contents of the plan. Would that that were true, but the proximity of the debate to the publication of the plan means that it is unlikely. The Executive's briefing document on the Scottish health plan said that it would be substantially complete by the end of October, although the minister has today suggested that that is not the case.
The minister should recognise the view, which comes from a number of organisations in the health field, that there is growing confusion about the Scottish health plan, except in the minds of some national newspaper journalists, who seem to know more about its contents than any member of this Parliament. In his closing speech, the deputy minister should take the opportunity to reassure Parliament that the plan is on track and that it will be published with an opportunity for a full parliamentary debate on its contents before Parliament goes into the Christmas recess.
I welcome the general thrust of the minister's comments. Like the Labour party, the SNP has always opposed the Tories' internal market. We did not oppose it only for ideological reasons—although I agree with Susan Deacon that the internal market was driven by right-wing dogma—but, like the Labour party, because of the dire consequences that the internal market had for the quality of patient care in Scotland. Patient care must be at the heart of any debate in this Parliament or elsewhere on the state of the health service. What the minister appears to be doing today is attempting to set out a route map to take us to the next step towards the complete dismantling of the internal market and all that went with it. That process started with "Designed to Care", but that document took us only half of the way. I welcome the minister's acknowledgement that much more needs to be done.
The proposals that have been outlined represent short-term changes to the way in which we structure the delivery of health care in this country, and I understand fully the reasons for that. In recognising, as the minister does, that there are a multitude of views about long-term change, I make an appeal to the minister that she not shy away from radical restructuring in the long term if that is considered necessary to rid ourselves of the last vestiges, to use her words, of the internal market and to deliver a health service that is driven not by the competing interests of the various health bodies but by the interests and wishes of patients in Scotland.
The SNP's proposal for a national health care commission, which was developed under my predecessor, is one that we have advocated many times in the chamber. I repeat today the strong argument for a national body to set the strategic priorities of the health service in a way that includes those who deliver and those who use the service in Scotland. I recognise that that raises real questions, to which Andrew Welsh alluded earlier, about the role and functions of health boards in Scotland. I also recognise that there are real questions about the number of trusts. The artificial barriers between primary care and acute services and between health services and local authorities affect the quality of service that patients receive. If those barriers were not created by the current structures, they are certainly aggravated by them.
Those are big questions, which require much consideration. I appeal to the minister not to shy away from the bigger questions in the longer term. Change is always controversial and will always be resisted by vested interests. As the minister recognises, if change is not managed properly, it can be an upheaval for those who work in and those who use the service.
There is a need to be bold. If the Government comes up with proposals for change that is in the interests of patients, the minister will have the co-operation of SNP members. Of course, structures are a means to an end and it is the end, which is the delivery of high and improving standards of care for patients, that is important. We all know that in many ways current structures impede the delivery of such standards. It is the Executive's duty to explain how any changes that it advocates make things better.
I will address three areas in which the governance and accountability of the NHS must improve. It is the minister's duty to explain how that will happen. First, I will discuss financial transparency. I note what the minister said in response to an intervention about funding flows. At the moment, it is virtually impossible to track effectively how money is spent in the national health service. For example, I reckon that it would be impossible for a member of the public—or indeed for a member of the Scottish Parliament—to find out how much of the additional funding that has been allocated to health boards to alleviate winter pressures has found its way into hospitals and is being spent for the direct benefit of patients. That is not good enough. We should be able to track how money is spent from the moment when it is announced in the chamber to the point at which it is used in the service to improve patient care. That is one of the keys to making the service more accountable at all levels, from the minister down.
Does Nicola Sturgeon share my concern that it took three and a half months from the announcement of the allocation of money for bedblocking for that money to reach health boards?
If Mary Scanlon listens to what I am saying, she will know that I share her concerns. We must tackle such questions to ensure the accountability of the service.
Financial transparency demands discipline at ministerial level to avoid, for example, double counting, repeat announcements or the surreptitious removal of money from the health budget to pay off housing debt. It also requires a simplified local structure that puts a premium on providing information that patients can access and understand. The minister must explain how the reforms that she has announced will make that possible.
Secondly, I will address the accountability and responsiveness of the NHS to the public. At the moment—the minister mentioned this—the accountability of health bodies is largely upwards, to the Scottish Executive. We must make it go downwards, too, to the Scottish public. No matter how many boards there are, we must ensure that they are genuinely accountable to and representative of the public. It is now three years since Labour took office, yet even now two thirds of health board members are men. That is not acceptable. In the debate on this subject in December last year, the Minister for Health and Community Care promised a boardroom revolution. What progress has been made? How is the democratisation of health boards to be progressed? How will the reforms that are being signalled today assist in the process? Those questions must be addressed.
This Parliament has debated the issue of public involvement in consultation before, and the Health and Community Care Committee should be commended for its work in this area. Only a health service that consults, listens to and informs its patients and staff will properly serve the public. We are still some way from such a culture of openness in the NHS. As the minister said last December,
"A patient-centred NHS must be more than just a slogan—it must become a way of life."—[Official Report, 16 December 1999; Vol 3, c 1709.]
The minister must explain how her reforms will take things forward, on micro and macro levels, both of which are important.
What are Nicola Sturgeon's views on the importance of health councils and their structure? Perhaps the minister could later address patient representation and the public accountability set-up.
Health councils have an important role to play in how we involve patients in the delivery of the service. I have various concerns about how health councils are currently structured, not least the fact that their independence from health boards is open to doubt. I have a commitment to the role of health councils, but would not shy away from admitting that reforms to the system are necessary.
I will return to my point: that we must do much more to involve patients in decisions about their own care. Too many patients still do not get basic information about their own experiences in the NHS. What progress has been made on the patients project, one of the Executive's key commitments? More generally, how are patients to be better consulted on the delivery of services in their own areas?
In the debate in March, sponsored by the Health and Community Care Committee, the then Deputy Minister for Community Care, Iain Gray, promised to revise and update guidance on consultation. What progress has been made on that front? How do we ensure that consultation is meaningful? One problem is that, even in cases when the public is consulted, they rarely feel that they are being listened to.
I will take the example of the acute services review in Glasgow—although I do not want to get into the detail. By any measure, there has been wide-ranging consultation on the review: there have been umpteen public meetings and thousands of people have been consulted. However, the proposals before and after consultation are virtually identical.
I know that, in a consultative process, not everybody can be satisfied, and that health boards need to take tough decisions, but when consultation appears to have absolutely no impact on proposals, I do not think that we can blame the public for being cynical about the extent to which their views are being listened to. If reforms are to be sold to the public, it must be made clear how they will make a difference; the public must be more involved in the delivery of a health service that truly belongs to them.
The third area that I want to cover is clinical standards and effectiveness. Talk of simplifying bureaucracy must not be confined to the delivery of service locally. I suggest that we need clarity and integration in the work of some national bodies, for example, the Clinical Standards Board for Scotland, the Health Technology Board for Scotland and SIGN, the Scottish intercollegiate guidelines network.
If we are to have a truly national health service, there must be nationally agreed standards of clinical effectiveness and nationally agreed systems of regulating the quality of care and of ensuring that performance lives up to the required standards. I welcome the minister's comments about new performance management systems that will monitor the whole of the service in the NHS. However, those systems need to be clearly understood not only by managers and health professionals, but by the public who use the system. I do not think that there is such an understanding on the part of the public at the moment.
Let us take the major issue of postcode prescribing. No one can deny that one of the major issues in the NHS is that, in many cases, quality of health care depends on where a person lives. As long as that remains the case, we have a national health service in name only. How is that issue tackled under the present system? It is not immediately obvious to anyone. Will it be by the Health Technology Board? Not according to its director, who expressly said that the board was not there to deal with postcode prescribing. There must be clarity about how systems and performance targets are set and about how they are monitored. That would ensure that we move away from a system that depends on locality towards a more national one with regard to the delivery of its service.
I welcome today's debate, but we must remember that talk of structures in the NHS is, on its own, meaningless to the general public. People are rightly interested in how they can influence decisions about the NHS on their own care and on the service generally. People are concerned about quality and consistency and how they can hold those in charge accountable when things go wrong. Those are the tests against which the Minister for Health and Community Care's announcement today will be judged. I look forward to debating the national health plan when it is published in mid-December and I hope many of the key issues can be taken forward constructively and, as far as possible, on a cross-party basis.
I move amendment S1M-1324.2, to insert at end:
"and further notes that the formulation and implementation of such proposals for change must fully involve both staff and the public and that such changes must be adequately resourced if they are to be successful."
Like Nicola Sturgeon, I welcome the tone of the motion, although I do not welcome the tone of the minister, which was unfortunate. I welcome the priority given to "improving governance and accountability" and the fact that "proposals for change" are set out in the health plan. I welcome Malcolm Chisholm to his new position and see it as a good example of partnership, as he was a member of the Health and Community Care Committee for 18 months and I am sure will bring forward many of our views and concerns.
The minister frequently refers to the internal market. If she seriously thinks that it is the major problem, I fear that she will miss the opportunity to thoroughly examine the deep-rooted, elitist hierarchy and culture of the NHS and she will not improve the patients' experience or help their voice to be heard. We must ask ourselves whether patient care is any better since the abolition of the internal market. We urgently await the response to the MORI poll in the health plan.
I welcome coterminous health decision-making boundaries. David Mundell has asked me to say that he would welcome consolidation of the health boards and trusts in rural areas such as Dumfries and Galloway and will be writing to the minister about that. However, where there is coterminosity—for example, in the Highlands—the problems are the same as, if not worse than, in the rest of Scotland. It is part of the answer but not the only answer. The 160 blocked beds in the Highlands—more than 10 per cent of hospital beds—show that the boards and trusts and the local council are not working together as well as they should.
Talk of governance and accountability must start in the Parliament with initiatives and examples. There must be clear lines of policy, priorities, objectives and targets in place to set a framework by which we can judge governance and accountability. It is difficult enough trying to unravel and understand the health budget when it has to be judged against so many strategies and plans—the priorities and planning guidance, "Towards a Healthier Scotland", "Designed to Care", the review of services for people with learning disabilities, the carers strategy, "Investing in You", the dental action plan, the report on work force planning, to name but a few. Although those documents all address serious health issues and priorities, it is time to tie the clinical priorities of cancer, mental health and heart disease in with those documents and with the budget so that clear signals, strategies and priorities are set out by the Executive.
If managers are to manage, they must be told what the priorities and objectives are, and the Executive must face up to and accept economic realities. I am not often sympathetic to NHS managers, but imagine trying to base decisions on the three clinical priorities, all the strategies, all the reviews and new legislation, perhaps with a few damning Scottish Health Advisory Service reports that call for funding thrown in. Then they discover that a new scanner is being provided that calls for £400,000 to train personnel and to run it. Then they must unblock beds, reduce waiting lists, get rid of the financial deficit, do an acute services review, a maternity services review and stand by their HIPs and TIPs—and now we have a new health plan. I do not often extend sympathy to bureaucrats but in this case I do.
As the Minister for Health and Community Care sits at the Cabinet table, handing over a few million here and a few million there for historic monuments, Forest Enterprise and the paying off of Glasgow's housing debt, she must tell the people of Scotland why those are greater priorities than front-line health care and how the new joined-up thinking with forestry leads to health benefits from the decisions to reallocate funds from the NHS.
Does Mary Scanlon agree that addressing the issue of housing is crucial when addressing the issue of health in a city such as Glasgow? If we address the issue of housing debt and release investment, we can do much more for the health of the people of Glasgow than we could by addressing the issue that she is prattling on about.
I thank Frank McAveety for his prattle.
If money were going towards investment in good housing and warm homes, it would help to address health care problems. That is what I would hope for. However, if the minister is to preach accountability, she has to accept responsibility and accountability. I can almost see that writing off Glasgow's housing debt could lead to investment in better housing, but if Frank McAveety, who is now on the Health and Community Care Committee, can tell me how money for historic monuments and trees can benefit health, I await his words of wisdom.
In this new world of focus groups and glossy brochures, we also have overlaps and interrelationships between such organisations as the Clinical Standards Board for Scotland, the Health Technology Board for Scotland, the clinical resource and audit group, SIGN and, of course, the National Institute for Clinical Excellence—NICE. Do we really need all those organisations as well as local drugs and therapeutics committees? Does the existence of all those bodies do anything to simplify and clarify the system and the lines of governance and accountability?
The minister should not create additional and separate organisations and then question why they do not collaborate. Devolution gives us the opportunity to integrate and simplify the structure of the NHS in Scotland. Last week, I submitted a question on the Public Health Institute for Scotland. Does it have to be a separate organisation from the Health Education Board for Scotland? Perhaps it does, but we need to be clear about it.
If the patient is to be at the heart of the system, local authorities in Scotland have to accept the responsibility of providing care in the community and the accountability and transparency that go with that. We should expect no less in standards of openness, transparency and accountability from councils than we expect from the health service. I look forward to the results of the MORI poll that will compare patients' experience of the NHS with their experience of our so-called local democracies.
A total of 10,000 people are waiting for assessment for home care and aids and adaptations, and a further 10,000 people have been assessed as needing care packages for which no money is available. Many such people end up in hospital, after which they cannot get back home because social work departments either refuse to fund their care or do not have sufficient funds. That failure to identify and address care needs not only fails the person needing the care but results in further complexity and confusion. In any partnership, the system is only as good as its weakest link.
Sutherland found that £750 million was being lost into what he described as a black hole between the allocation of money to councils and the provision of care. That figure equates to £75 million for Scotland. I am told that many councils spend money on children's services. I do not doubt that children's services are a priority, and I do not doubt the worthiness of investing in them. However, when money is earmarked for care of the elderly, we have to ensure that such decisions are transparent and clear, and we have to hold councils to account for their spending.
As far as councils are concerned, the problem is not theirs. As long as a person is being cared for in hospital, it becomes convenient for councils to pass the buck. That results in delayed discharge, bed shortages, longer waiting lists, inappropriate care and treatment, and cancelled operations. We cannot keep throwing money into councils to solve NHS problems. Openness and partnership working must be welcomed. The more chaos councils create, the more money they get. However, we do not know how or why they spend their budgets on community care. I hope that the minister will include that in the health plan.
The elderly do not complain, nor do the mentally ill. However, yesterday, the Mental Welfare Commission for Scotland published a damning report. The same problems arise in the care of the mentally ill as they do in the care of the elderly. The director of the MWC, Dr Jim Dyer, said:
"The Commission is aware of many people about whom there is unequivocal agreement that they need residential or nursing home places or other community care, but who remain in hospital—often for many months or even years—either because there is no apparent local authority funding for their placement or there is disagreement about responsibility for funding."
Given that we have had and are currently pursuing a phased programme of closing down the old psychiatric hospitals to offer care closer to the patient and more appropriate to their needs, it is totally unacceptable that patients are entering psychiatric institutions and find themselves unable to get out.
Last week, at my surgery in Inverness, I was visited by a lady whose mother had been in council residential care and had been taken to the local psychiatric hospital for a two-week assessment. Four months later, her mother was still there—her room had been reallocated and her clothes and belongings stored in a cupboard. The residential home said that that was not its decision and the hospital said that it was not its problem. The doctor said that the matter was out of his hands. When the lady finally tracked down a councillor, he did not want to know. For that case and others, I welcome the initiative that recognises that the patients voice must be heard. I hope that an update of the patients' charter will be introduced to ensure that patients and their families know who is in charge and whom to go to if there is a problem.
There is a need for a common agenda. In Inverness, prisoners who had come off drugs and had come to terms with their habit were released into the community and there was no care for them. There is a new initiative in place and the governor of Porterfield prison is working closely with the primary care trust, which has provided a drugs officer in the prison for three days a week. It should not need parliamentarians to tell people to do such things. It is about good practice, good will and putting the patient first.
I am also concerned that most diagnoses of autism are when children are six or seven years old. Previously, I raised with Peter Peacock the issue of testing and diagnosing children in nursery school. Autism is diagnosed once children have failed to keep pace with the first year in school. Given the dramatic rise in autism, we should introduce a system in which health visitors, general practitioners and others can apply the tests to ensure that early diagnosis is made to allow children access to care and treatment.
If we do not start to give the patients information, the patients will start to give us information. Many doctors and consultants are faced with the latest downloaded, wacky American version of a wonder cure for their ailments—the patients turn up with pages printed from the internet. In that respect, I am pleased to hear that the SIGN guidelines will be printed in patient-friendly language, so that patients know what to expect.
I welcome the debate. I hope that it will lead to a clear structure with clear lines of accountability and will reduce the bureaucracy that has bedevilled the history of the NHS.
Before I begin my speech, I would like to welcome two people. I welcome our erstwhile poacher turned gamekeeper, the new Deputy Minister for Health and Community Care, Malcolm Chisholm. I enjoyed Mary Scanlon's comment that Malcolm Chisholm had been with the Health and Community Care Committee for 18 months. It had a slightly menacing tone, as if to say that the committee has knocked him into shape and now thinks that it is safe to let him go on to bigger and better things. I am sure that he will do an excellent job in his new post. He has the best wishes of all colleagues on the committee.
I also welcome Trevor Jones, the new head of the Scottish Executive health department and chief executive of the NHS in Scotland, to what has been described to him on many occasions—certainly by all members of the Health and Community Care Committee—as a bit of a poison chalice. I am sure that he, too, will rise to the challenge of his new post.
The important point to come out of today's debate is that there is an appetite for change. That may be expressed by different people from different parties in different ways, but it is based on a sense of great frustration: frustration for individual MSPs arising from their casework; frustration for the Minister for Health and Community Care in dealing with the range of health issues that she has to deal with; and frustration for members of the Health and Community Care Committee as we try to tackle the issues in the health service. There is a sense of frustration that it is almost impossible to come to terms with the reality of the governance, accountability and issues at the heart of the health service in Scotland.
I will use an analogy that I sometimes use when talking to people in my constituency—it may have something to do with the fact that I have relatively young children. I describe trying to come to terms with the role of convener of the Health and Community Care Committee—and I mean no disrespect to my colleagues on the committee—as having to deal with a great big blob of green slime, which from time to time my children throw around our house and which ends up all over the carpet. You feel that you have it contained in your hands, but suddenly it squeezes out of your fingertips and it is all over the carpet. That is how I often feel when dealing with health service issues. I feel that I have everything in a nice little box, and suddenly something pops out of the other side. In talking about governance and accountability, we are considering wide-ranging issues. From that sense of frustration, probably every member of this Parliament will be able to tell the minister what the problems are, but we, as a Parliament, have to try to help the minister to secure the right results and the right way forward.
As I said in committee in March, the national health service in Scotland is a secret service. It is meant to be about patients' needs, patients' care and patients' journeys, but those of us who deal with it find that the reality does not match the rhetoric. Through the consultative steering group, we have a Parliament that is meant to be open and accountable. We have structures—our committee system, for example—that are meant to be open and accountable and looking at the health service.
I will work my way through some of the governance and accountability issues that we have examined in committee. In March, we had a debate about consultation. The issue came to us on the back of two petitions—one about Stracathro hospital in Tayside and the other about the Stobhill hospital medium secure unit in Glasgow. We found that consultation had not been followed through effectively or properly, either with the populations of those areas or the staff. We found that there was wonderful rhetoric in wonderful documents about the importance of health service staff and how, when there is change, they should be taken along and their views should be taken on board from day one. The staff should not hear about change in local newspapers, yet time and again they hear about it from behind somebody's hand and in their local newspapers. They are the last to know about massive changes that affect their lives and those of their families.
What should we be doing about patients? At the moment, the average patient is probably not even adequately informed about their own difficulty, never mind being given effective information and being involved. They are not being, in Richard Simpson's words, informed, engaged and consulted. There is no point in someone being informed, engaged and consulted if, at the end of the process—when they have had their say, informed themselves, engaged in the process and been consulted—their words count for nothing. We have to get away from believing—and giving patients and the people of Scotland the impression—that the only voices that are listened to are those of clinicians and not those of patients.
I want to know from the minister what progress has been made to change the guidelines that the committee talked about in March. It was clear that Greater Glasgow Health Board had not done everything that it could have done. More shocking, however, is the fact that it had done everything that it was asked by statute to do. Guidelines exist on change of use, but they are 25 years old and do not deal with new developments. There was great confusion, and I would like to know what progress has been made.
The committee has also undertaken a review of community care. Time and again, the message that we have received is that there is a need for transparency. We hear stories about resource transfer, which involves long-term care beds being shut down to provide resources for community care services. Transparency is patchy across the country. For each bed that is shut down, more is paid in some areas than it is in others. In some parts of the country, the system is working and is transparent but, in others, councils have lost out.
I can answer Mary Scanlon's comments to some extent by saying that councils are central to effective health care. In addition to their statutory role in community care, they have important but non-statutory roles in day care, the provision of healthy homes and the promotion of health in our schools. Time and again, we have seen that the way to improve the health of our country is to bring together the health service and local government.
Irrespective of what I think about Sutherland—I still believe that the Executive got its response wrong—I agree with the Executive's programme of joint working. By 2002, councils and the health service should be working together to provide a jointly managed and jointly resourced service through joint working. If that is good enough for community care, it is good enough for health services generally. If we do not appreciate and nurture an effective partnership between the health services and local government, we will do nothing to improve patient care.
The budget is an example in a nutshell of a major problem of transparency. I believe that Susan Deacon has an appetite for change. She has shown that in much of her work and in some of the root-and-branch changes that she has made in her department. In most of what she says, she is backed by the vast majority of members. Let us consider an issue on which we all agree: the need to take forward health promotion and the public health agenda. When the minister says that we will receive £26 million from the tobacco tax and that that money will be invested in public health, everybody says, "Yippee! What a good idea." However, we should ask throughout the process, "What happens next? Where has the money gone? Who has it gone to? Who is responsible for it?" In the end, the question is whether the services on the ground—the results that we want—have been delivered.
I believe that the minister, the Health and Community Care Committee and the Parliament have an appetite for change and are crying out for a system of accountability in which we can consider departmental budgets. Unfortunately, in considering the budget of the health department, the Health and Community Care Committee cannot say whether the aims of the Minister for Health and Community Care and the Executive are being followed through. That is not right. We may not have to know where every pound is being spent, but we need to know whether the priorities that are identified by the Executive—whether cancer care or public health—are being taken forward effectively. We have to know whether there is a shift in funding from the acute sector to the community sector.
We must know about those issues because they form the basis on which we will tackle the major problems identified not only by the minister and the Executive but by members of all parties. We must tackle those problems in order to improve the health of our country. There is a massive problem with the budget, with which the new Minister for Finance and Local Government will have to come to terms before we go through the budget process again next year.
The Health and Community Care Committee's work on the Arbuthnott report is a further example of how we have highlighted problems in the health service. I try not to mention the "A" word often, as it has all sorts of memories for me. The committee did a good job on the Arbuthnott report, but we worry that, although we secured a better settlement under Arbuthnott 2—if I may call it that—than under its predecessor, there is nothing to tell local health boards and trusts to use the money that we have made available to them to tackle the inequalities that we have identified as a stain on the country's health. That is despite the fact that the country and the Parliament have decided to tackle health inequalities in our cities and rural areas, saying, "There's the money—go and do it." We must get to the bottom of that problem.
There are lessons to be learned from the way forward on community care that the minister and others are pursuing. We want joint working. We want to eliminate the layers of decision making. We want clarity and transparency from those responsible for decision making.
The minister should consider the long-term approach and make root-and-branch statutory change by eliminating some health boards—there is a great deal of sympathy among members for that approach. However, if we do not go down that route, we should ensure that everyone gets round the table and that we eliminate a layer of health governance so that results are achieved at the practical level.
We now move to the open part of the debate. Members should keep their speeches to four minutes, so that all who wish to speak can be called.
I welcome this opportunity to influence the shape of governance and accountability in our national health service in Scotland, which will be addressed in the first Scottish health plan. I stress the phrase "our national health service", as some who work in the service have forgotten that the national health service in Scotland does not belong to them.
The culture of competition ruled for many years—certainly for more years than I care to remember. That culture did not take account of patients' views or ask for the involvement of staff. However, the minister has delivered significant funds to provide a basis on which we can be proud of the national health service in Scotland once again. Unfortunately, those funds are not reaching the parts for which they were intended.
The minister announced £1.477 million for Ayrshire and Arran Health Board on 21 September, in order to kick-start the Arbuthnott redistribution of resources. I asked her then for an assurance that the moneys would be spent in accordance with the Arbuthnott principles. The minister assured the chamber that the moneys would be directed to
"address needs wherever they arise in Scotland."—[Official Report, 21 September 2000; Vol 8, c 510.]
My colleague Cathy Jamieson and I met representatives of Ayrshire and Arran Health Board on 25 September, in order to ensure that they were in no doubt about our aspirations for the new allocation. We were surprised, therefore, to read in local newspapers last week that the health board has decided to use those moneys to offset its anticipated overspend.
The Ayr Advertiser reported a stormy meeting of the health board. At that meeting, Gordon Wilson, who is chair of the Ayrshire and Arran Acute Hospitals NHS Trust, stated:
"There could be serious questions asked of us why we have not used this money for the purpose it was intended."
Aileen Bates, who is chair of the Ayrshire and Arran Primary Care NHS Trust, stated:
"I feel uncomfortable about making an on the spot decision about this, without knowing what improvements will happen next year. We should be more imaginative about this."
However, the board took the advice of the health board's director of finance and chief executive. The health board's chairman commented:
"Recent money has not been able to reduce the deficit. By using this money"—
the Arbuthnott money—
"for this purpose, the board will not have to cut into its health improvement plans for next year."
I find it incomprehensible that no clinical input was given to the health board in reaching that decision. On the other hand, it would be difficult to have clinical input, as a director of public health for the Ayrshire and Arran Health Board area has yet to be appointed.
People in Kilmarnock and Loudon deserve better than that from an organisation that is supposed to have their health interests at heart. It is clear that those on Ayrshire and Arran Health Board do not share the minister's objectives for improving health. It appears that they are not accountable to her, as they can interpret her guidance as they like. My colleagues and I will not sit back and allow unaccountable health boards, such as Ayrshire and Arran Health Board, deliberately to ignore the needs of patients, staff and elected representatives and to squander hard-fought-for moneys that could make a difference.
I reiterate calls that I have made before in this chamber to make changes before it is too late. It is no longer acceptable for one organisation in isolation to determine the health improvement programme and for trusts to arrange their trust implementation plans around it. If we are serious about holistic, patient-centred health care provision, one plan in which all stakeholders are equal must be drawn up in the short term, while we consider the options for the longer term. We will then have an opportunity to deliver our priorities, not those of the health boards.
We have just heard the voice of experience from Margaret Jamieson, who has a practical NHS background. I agree with what Margaret Smith said about the appetite for change that derives from frustration. That is a good summation of the current situation and I have no doubt that that emotion is shared by MSPs and members of the Executive. Any proposed changes must get it right this time.
Management and accountability in the NHS are fundamentally all about the role, functioning and conduct of quangos. Quangos, by their very nature, are unelected, unaccountable bodies filled by Government appointees. In reality, they are accountable to no one. The promised new Labour bonfire of the quangos never happened. That is typical of Brian Wilson; today's promises and boasts of actions are tomorrow's inaction. Until quangos are either abolished or brought under democratic control and scrutiny, those problems of management and accountability will continue.
How did Tayside Health Board and the health trusts manage to receive more money each year than any other health board and still end up with a massive £20 million or more annual revenue deficit? What about the pensions and perks scandal? Those are both symptoms of a deeply flawed system. Sending in hit squads and sacking the occasional board chairperson—the self-same person whom the previous Government appointed—will never solve the fundamental democratic and organisational flaws that are built into the health board and trust quango system.
I know from past experience that trying to get individual Tayside Health Board and Angus NHS Trust chairmen to attend a public meeting is like drawing teeth. Massive decisions affecting hospital services for the whole community, service closures and large-scale staff reductions have all taken place behind closed doors with minimal or non-existent public consultation. Indeed, for many years, those decisions were taken without any Angus citizen being represented on the health board. Until recently, health board and trust meetings were not even held in public. That is unacceptable in a modern democracy. At the heart of those problems is the culture of quangos and Government appointees. Whichever Government democratises this system, it will have done us all a great favour. Greater public participation and accountability has to be built in as a natural part of the system.
Tayside Health Board and the health trusts have now instituted briefing sessions for MSPs and MPs. That is to be welcomed, but the consultation must be genuine and it must be extended to include the public, whom the system is meant to be serving. I am not alone in being sceptical about the whole series of public meetings as Professor Rowley goes on another autumn tour of Tayside with totally uncosted options. Nor am I alone in expressing scepticism about the establishment of so-called focus groups that is now under way. The people of Angus do not want wish lists or deliberative conferences with Angus minority representation and conclusions that are obvious even before the meeting is held. They do not want meetings based on completely uncosted and untenable options, or anything else dressed up as consultation that clearly is not.
Government appoints quangos, and it must ensure that management and accountability are built into the organisation and conduct of those bodies. In Tayside there have in the past been dramatic failures in management and accountability. There must be improvement and, once introduced, that improvement must be permanent and firmly based on democratic accountability. That is the basis on which the success or failure of the minister's proposals will be judged.
I was greatly encouraged by the minister's speech. Like many members, in the coming months I will watch with keen interest what happens and how the proposals are put into practice.
I was also encouraged by Nicola Sturgeon's speech, because she made a number of relevant and pertinent comments. In this debate, we are beginning to see a consistent message coming from members across the political parties that something is wrong and that something needs to be done.
However, I despaired at times while listening to Mary Scanlon. She talked about patient-friendly language but then introduced us to the word "coterminosity". She also seemed conveniently to ignore the damage that the Conservative Government caused during 18 disastrous years to the health service and to the councils that she criticised.
If we are to achieve anything from this debate and in the health service more generally, we need to re-establish the simple principle that the health service should exist to help people, when ill, to get better as quickly as possible. We must reintroduce simplicity into the system. As has been said, how can people understand the system when their first point of contact with what they think of as one entity—the NHS—is a representative of the local health care co-operative? If patients from Paisley South need help out of hours, they must turn to Renfrewshire emergency medical service—another unit. If they are hospitalised, they become the responsibility of the acute hospital trust. They may then have to transfer to the primary care trust. Because of Paisley's proximity to Glasgow, there are also times when patients have to transfer to the South Glasgow University Hospitals NHS Trust. In the meantime, they must deal with community pharmacists and the dental services. At the end of the process, they may have to engage with social work, which in turn has to deal with the voluntary sector and nursing homes.
This morning we heard in the minister's speech other examples of the complexity of the system that baffles people. We must talk in a language that people understand. The minister referred to HIPs and TIPs. When people talk about hips, they mean replacements. When they talk about tips, they mean places where they take their rubbish. This should not be a debate between politicians and professionals; it should be a debate about the public, who need a service. I am showing my age here, but the tenor of this debate sometimes reminds me of the words of a parody by the Clancy Brothers of Galway bay, who sang about people talking in a language that the clergy do not know. Politicians and professionals often talk in a language that the public do not and cannot understand. We must bring the debate back down to their level.
We must ensure that consumer and staff alienation is ended. We need a system that is easily understood, transparent, accountable and effective. We need to renationalise the health service so that it achieves its aim of meeting the needs and aspirations of people who are ill and need the service immediately. This debate has signalled welcome progress, but we must work hard to achieve those aims.
I note the wording of the motion, which for once is not self-congratulatory—it is pure motherhood and apple pie and is difficult to disagree with on principle. I welcome the fact that the minister has given MSPs this opportunity to influence the debate, but we must ask the Executive what is meant by "improving governance and accountability".
I base my speech in part on the guidance note on clinical governance that was issued in 1999, when Sam Galbraith was health minister. The document proposes that the trusts should have clinical governance committees. What powers will those committees have? We must recognise that the committees and clinical governance per se will not necessarily deliver a better service. I hope that they will, but I fear that they might not. I am certain that they will increase paperwork and red tape. We must ask whether clinical governance and accountability will reduce waiting lists and waiting times because, in many cases, the length of waiting time affects the outcome of clinical treatment.
Will those "meaningful and practical proposals" cut by one the 6,600 people on waiting lists in the Ayrshire and Arran Acute Hospitals NHS Trust?
Will Mr Scott give way?
No thanks, Margaret.
Will clinical governance reinstate to previous levels podiatry care or lip-reading services in Ayrshire? Most people in Ayrshire feel that services are decreasing, not increasing.
I fear that the new rules and regulations may take away individual accountability from any doctors and staff who might set out to deliver minimum standards. Doctor will have to check on doctor and nurse will have to check on nurse, which will mean that they use up valuable time on assessment and report writing—time that could have been used to deliver medical services. A danger is that a new tier of hospital bureaucracy will be created, using up valuable funds but not necessarily delivering a better service.
Morale is at an all-time low in the NHS. Clinical governance and accountability could lower that morale even further if doctors and nurses feel that they are being continually assessed and that regulation is being imposed from on high. Instead of rewarding and encouraging responsibility within the NHS, clinical governance committees may take the individual's personal pride and accountability out of a system that is already creaking at the seams, as Margaret Jamieson pointed out.
Who will guard the guardians? Who will monitor the monitors on those committees? I want the Executive to answer that. The more that the Executive has sought to control the NHS, the less well managed it has become and the more morale has fallen. The political interference that we have seen by Susan Deacon excludes the professionals, such as doctors, nurses and the British Medical Association; it has weakened the health service, not strengthened it. Last winter's debacle and the subsequently revealed £135 million underspend is a case in point.
Will the committees reduce bedblocking? Money has been thrown at that problem with little or no result. National health and social work budgets must be integrated. I commend the start that has been made to that in the Borders and as outlined in the report "All our Futures".
Local solutions and local accountability is needed. Will the Executive impose national guidelines of clinical governance or will it allow each trust to set its own local standard and benchmarks? If the Executive sets minimum acceptable national standards, will it give extra money to the least good hospitals? If it does that, will it have to take money away from successful and well-run hospitals? Will individual hospitals be able to set their own targets within their own trust, which would mean that the variation in clinical care across Scotland would continue? What will clinical governance committees do if their recommendations are not followed? We must hope that a position of last resort will not be needed. If it is, however, we must know what ultimate sanction the committees will have.
Those are just a few of the questions that require an answer. I look forward to the hearing the minister sum up.
I shall focus on financial accountability and the transparency of information on health expenditure nationally and locally.
I welcome the efforts that the minister is making to respond positively to the concerns, which were well expressed by Margaret Smith, about the pervasive culture of secrecy in the bureaucracy of the NHS, but the credibility of those efforts would be greatly enhanced if the Executive set a better example. The surreptitious transfer of the £44 million that was accumulated by NHS trusts under the internal market system out of the NHS to facilitate a wholesale housing stock transfer in Glasgow is a case in point. Throwing up the smokescreen of Treasury rules to try to obscure a political fix merely served to compound a blatant error of judgment.
I am sure that the minister will acknowledge the fact that the NHS needs every penny it can get. If that £44 million was available only for debt repayment, the sensible course of action would have been to deal with the current debt problems of the NHS trusts. The situation in Tayside, for example, has been highlighted in this Parliament.
Decisions such as the transfer have a knock-on effect, frustrating policy aims and objectives and throwing the whole process of accountability into disarray. The Executive has made much of its initiative to tackle inequality in the provision of health care through its implementation of the Arbuthnott report recommendations. Reallocating NHS resources among health boards to ensure that the impact of social exclusion and the needs of deprived and rural areas are fully addressed throughout the country is a laudable aim.
Margaret Jamieson illustrated, however, how Ayrshire and Arran Health Board has thwarted the Executive's intentions. The unpalatable truth is that the health board will get away with its decision—as it has with others, such as its suspension of the further development of mental health services despite that being one of the three NHS clinical priority areas—because of the absence of appropriate local accountability mechanisms and a lack of political will, on the part of the Executive, to direct health boards. I am not convinced by anything the minister has said this morning that such fundamental flaws in the system are going to be tackled effectively.
There appears to be a complete lack of appreciation on the part of the coalition parties and others in this Parliament of the big picture of health spending. The tightening grip of the Barnett squeeze on the NHS in Scotland is a major threat that is looming on the horizon. At the moment, the health service in Scotland receives funding that is roughly 20 per cent higher per head than that which is received by its English counterpart, but the Barnett formula is designed to eliminate that differential.
The latest academic research suggests that a convergence with the spending per head in England will proceed rapidly and that, in the next few years, the per capita spending differential will dip below 15 per cent. The differential was established in the 1970s as what was required to meet the greater level of need in Scotland due to the higher incidence of social deprivation and the sparsity of the population. When convergence happens, the chickens will come home to roost with a vengeance in this Parliament, exposing the inadequacy of the devolution settlement. The problems that are associated with NHS governance and accountability will be compounded manyfold.
This debate is about inheriting the legacy of the NHS and reinventing the service for the future. This morning, the minister addressed several of the issues that affect the NHS, including investment, reform, modernisation and accountability—which are much more interesting than Adam Ingram made out. He reminds me of the individual who once went into a bookshop and asked, "Where are the books on revolutionary socialism?" only to be told by the tired old bookseller, "Where they've always been, son—just round the corner." Instead of engaging with the issues, as the minister did, Adam Ingram is merely waiting for what he thinks will be an inevitable failure of the devolution settlement.
The issues centre on how we reinject public service values into an NHS that has lost them over the past 20 years because of the ideology of Conservative Governments and on how we modernise the system to take account of the fact that the world has changed since Nye Bevan introduced the NHS in 1948, against the clinical views of those who dominated the profession.
How do we change the legacy of the NHS that we have inherited? Rab Butler once said of the civil service that it is a great system but no one is quite sure what to do with it. The same comment could be made of the NHS, and the minister has identified the importance of the Scottish health plan over the next months and years.
Hugh Henry and other members have pointed out that the main issue is the legitimacy of the health service: it matters to folk because it has made a difference to their lives and experience. It is in that light that it is critical we understand the history of the NHS. How can we relegitimise the NHS in the eyes of a public who feel excluded from decision making? I am not just referring to some of the issues faced by my colleagues in Glasgow and elsewhere in Scotland; the question is how we break down the bureaucracy of health boards and health trusts, no matter what public office we hold. Many of us had experience of public office before we became MSPs, but even those who had access to information and power did not have a clear understanding of where health service decisions are made. We need to address that issue.
I welcome the minister's commitment to put patients at the heart of the service and to reduce bureaucracy, but how do we integrate decision making at a local level? Having spent a period of time in local government, I know that the critical issue is marrying the democratic credibility of local government—which should continue to consult the public—with the provision of a health service.
I am not arguing for a return to the 1920s model, when councils ran health provision; we need to create partnerships to integrate decision making much more at a local level. Furthermore, that problem will never be addressed by the internal market, no matter how many times John Scott and others invoke its memory. That system clearly failed the health service after it was introduced as part of the radical Tory plans of the 1980s and 1990s. Instead, we must use the experience of our communities to influence, shape and configure the health service for the future. That approach will work because, despite Adam Ingram's comments, the health service will receive more investment than ever before. The challenge is how we use that investment to make a real difference.
Does Frank McAveety disagree with the claim of the British Medical Association and the Royal College of General Practitioners in their submission to the Scottish health plan? They say:
"Clear benefits in relation to the monitoring of the quality of hospital services which were inherent in the internal market have been lost to the detriment of patient care."
Have all the doctors got it wrong?
I welcome their contribution, but I have the right to disagree with them—and I profoundly disagree with that singular perspective, which does not take into account many other issues that impact on the health service. Given the comments from many members this morning, we do not necessarily agree with the idea that doctors as professionals alone can give us a perspective on the health service.
The real challenge is not to have a bonfire of the quangos, which is a call I heard again from the Opposition; indeed, I would welcome the quieter velvet revolution that Susan Deacon suggests. Local government is changing. The community plans that will be central to the development of any local government legislation will marry well with a modernised agenda for the health service. I welcome many of the minister's comments and hope that we can move forward with these ideas.
I welcome this debate on NHS governance and accountability. Since I became an MSP, I have felt great frustration in trying to get to grips with who does what and which organisations are responsible and accountable for the decisions taken in the health service. Governance and accountability have caused a great deal of concern in my constituency. The local community has expressed concern at the large number of NHS quangos, their lack of accountability and their physical remoteness to many of the communities in Argyll and Bute. Above all, there is concern due to the perception that local communities cannot influence the decision-making process.
A range of organisations are responsible for or impact on the delivery of health care in Argyll and Bute. The list is long. At the bottom tier—the front-line troops—there are two local health care co-operatives, which manage general practitioner services.
We now have a primary care trust—Lomond and Argyll Primary Care NHS Trust—which is an amalgamation of the old Argyll and Bute NHS Trust and Lomond Healthcare NHS Trust. That has resulted in the one trust having two headquarters. Executives spend their time travelling up and down the road between Lochgilphead and Dumbarton, with no one very sure where the real headquarters is. Two local authorities work in partnership with the primary care trust to deliver community care. Again, three organisations must work together.
Alongside that is an acute trust—Argyll and Clyde Acute Hospitals NHS Trust—which manages Inverclyde hospital, the Royal Alexandra hospital in Paisley, Vale of Leven hospital and three quarters of the Lorn and Islands district general hospital in Oban. Oban is in the ludicrous situation of having two separate trusts—the primary care trust and the acute trust—managing different parts of its hospital. What a bizarre situation.
On top of all that, we have Argyll and Clyde Health Board, the NHS management executive, the Scottish Parliament—this new institution in which we represent our areas—the Parliament's Health and Community Care Committee and the Scottish Executive. In all, nine different organisations impact on the delivery of health and community care in my constituency. Is it any wonder that doctors, nurses and local communities feel remote from the decision-making process?
The hospital in Oban is a classic example. It was only when the people of Oban rose up in protest at rumours of closure and change at the hospital that the trust management responded and came to Oban to speak to the community. The cause of the community's concern is that it has a hospital on its doorstep that is run from 100 miles away. That is the equivalent of a hospital in Edinburgh being managed from Newcastle. Would the people of Edinburgh put up with that? I think not.
It is time for a rethink. I disagree with Frank McAveety. In a new, devolved Scotland, we do not need layer upon layer of quangos. It is time to bring the decision-making process back to local communities. We need to give local communities a sense of ownership and of identity, so that they feel that the relevant body belongs to their community. Above all, we need to give them the belief that they can influence the decision-making process. That belief is not present at the moment.
Surely it is the role of the Parliament to make the big strategic and investment decisions, but then to provide resources directly to doctors and nurses in the front line, to let them get on with delivering a top-class health service. Let us cut out the layers of bureaucracy that sit between us and the front-line troops.
I recognise that such changes cannot be achieved overnight. The NHS is only just recovering from the most recent major shake-up. Staff morale is an issue and I do not believe that staff could cope with a further reorganisation right now. Nevertheless, the issue cannot be ducked. It is not good enough to say that partnership working is the way forward; partnership working is not the answer in itself. By the time all the organisations that impact on decision making in the health service in my bit of the world engaged in partnership working, there would be precious little time left to deliver health care.
I appreciate what the minister has said today, but I recognise that it is a first step in bringing accountability back to local communities. The overall goal must be a radical shake-up of the convoluted NHS structure, leaving us with a much simpler NHS structure, as befits the new, devolved Scotland.
I support the motion.
I would like to continue the theme of transparency and accountability in the NHS in Scotland that many members have talked about today. In particular, I want to talk about the need to let people know what is happening on the ground in the NHS. I will concentrate on the condition of medical equipment in our hospitals, consider the implications for patient care and seek a response from the minister, who, unfortunately, is not in the chamber to hear my speech.
A few months ago, there was an enormous furore in the Scottish Parliament when it was revealed that there was a lack of investment in equipment in our hospitals. We also dealt with the issue of the underfunding of radiology equipment, which was brought to the fore by Professor Jamie Weir of Grampian University Hospitals NHS Trust. The minister must understand that the radiology issue is only the tip of the iceberg with regard to the condition of medical equipment in our hospitals.
It is extremely difficult to get national information on the state of medical equipment in our hospitals, yet that is essential to the delivery of proper patient care. I had to conduct my own investigation in Grampian. Correspondence from management in the NHS trust told me that 25 per cent of general medical equipment in that area's hospitals is beyond what is referred to as its standard life. In other words, a quarter of general medical equipment in the area should have been replaced long before now.
I recently lodged a parliamentary question about cancer treatment waiting times in Tayside and discovered that that area has the longest waiting times for cancer treatment in the country. One of the reasons given by the health authorities in the area is that the equipment is old and has broken down. What are the causes of that? There is a general lack of investment. In its letter to me, the medical management of Grampian told me that matters are "less than satisfactory". On general medical equipment, the letter says:
"There has often been a gap of over £500,000 between what is requested each year and the funds that the Trust were able to make available under this heading."
There is also the issue of how funds are allocated. Often, it is a case of use it or lose it. A radiology department might want to buy a machine that costs £1 million, but is unable to save money from the £500,000 it gets each year—it all has to be spent. The minister has to sort that problem out immediately. There are implications for the reliability of Scotland's medical equipment. As happened in Tayside, equipment breaks down if it is old.
If equipment is not modern, we cannot maintain a proper standard of health care in Scotland. In the Royal Aberdeen children's hospital, one piece of equipment gives one tenth of the dose of radiation treatment that the older equipment gave last year. It will bring enormous benefits for the health of patients. Generally, however, the standards are falling behind. A new computed tomography scanner in Aberdeen hospitals is able to examine 40 patients a day, but the infrastructure in the hospital makes it possible to examine only 20 patients a day: the same as was possible with the old machine. The state of our medical equipment and the lack of infrastructure mean that we cannot keep up with modern standards in the health service.
If we ask our medical staff to use older medical equipment, there will be implications for patient care. We know that claims for compensation worth many millions of pounds are made against hospitals every year. What is causing those adverse events, as they are called, in the health service? Perhaps it is the fact that our medical staff are being forced to use out-of-date equipment that is not appropriate to the job in hand. Let us try to find out what lies behind those claims, as is happening in England.
I call on the minister to ensure that there is an immediate audit of medical equipment in all Scotland's hospitals. We must find out what should have been replaced before now, so we can address that problem. The national health service needs a national policy and national statistics. I agree with the modernisation of the health service that the minister talked about, but I do want the medical equipment to be modernised as well as the bureaucracy.
Unfortunately, yet again, my amendment has not been selected. However, I hope that today's debate marks a new trend in the politics of our new Labour colleagues. It is a long time since I have been able to agree on a political matter with Hugh Henry, but I find myself in complete agreement with him today. He used a phrase that heartened me. He said that it is time to renationalise the national health service. I hope that that is not the last time we will hear that term being used and that we will hear it further in relation to our rail, gas and electricity.
I hope that the minister will agree that there are some absolute prerequisites for improving the governance and accountability of the national health service. First, there has to be the fullest possible democratic involvement of the health workers' unions, the patients' representatives and the professional organisations. That involvement has to be real and based on consensus and democratic judgment. We should not have—as happened with the problems with higher still and the Scottish Qualifications Authority—a profession that is acutely opposed to major change and therefore not willing or able to deliver it. There has to be involvement of those who work in the national health service and those who require it.
Another prerequisite is that there should be an overhaul of our boards and trusts. There is no place for those unelected, unaccountable quangos in a new, modern, renationalised national health service. We need the involvement of the health workers' unions, which represent the nurses, auxiliaries, cleaners, technicians and porters. We also need the patients' representatives and the professional organisations, but their participation must be on an accountable basis.
Of course, that is all just talk if it is not matched with resources. We cannot improve the governance and accountability of our health service if it does not have the resources that are required. There is a multiple sclerosis scandal in Scotland. There is a huge problem in cancer care. We have a disgraceful situation in relation to autism and other child disorders. I know that both ministers want to tackle those problems, but that cannot be done unless there are sufficient resources. If those who use the health service are to be more satisfied, we have to provide the resources to allow the staff to deliver that service.
We already have a complex set of statutory requirements for clinical governance in relation to such matters as clinical risk management, which is supposed to reduce litigation costs. It is supposed to encourage an honest assessment of situations when things have gone wrong so that measures can be introduced to avoid similar problems in future and so that there can be early communication with, and explanation and apology to, patients or potential litigants. The difficulty is that in a service that is under-resourced or understaffed, it is much easier to apportion blame and to have a culture of blame.
The member may be aware of the organisation with a memory project in England, which tries to move away from the blame culture and to get at the root of problems in cases of compensation claims, such as stressed workers or the lack of good equipment. Does the member agree that we need such a study in Scotland?
I agree 100 per cent about the need to mimic the practice to which Richard Lochhead refers. However, I hope that we will not mimic another practice in England—I will seek an assurance from the ministers on this. As part of the national plan in England, there is a move towards the naming and shaming of hospitals that do not meet certain targets and requirements. Unless there is adequate resourcing, targets mean nothing to hospitals and staff.
There is a complex set of rules, which many trusts are not following. Because of reorganisation, deficits and winter pressures, the service is firefighting and staff morale is at rock bottom. The Executive will be unable to deliver an improvement in the governance and accountability of the health service unless the service is properly resourced. Will ministers agree that the Scottish health plan must be properly resourced and must deliver, as Hugh Henry said, the renationalisation of our health service in Scotland?
Speeches should now last less than four minutes, please.
As I am coming down with a cold, and given that a lot of points have already been made this morning, I will cut out some of my speech—I am sure that you will be pleased about that, Presiding Officer.
I agree with much of what Margaret Smith, Hugh Henry and George Lyon said. It is no longer enough that health services are simply presented to the user. Public ownership should not solely mean state ownership, but that each individual, each family and each community has a stake in the NHS, with associated rights to involvement and consultation. Those are not just the rights of a consumer; they are the rights of a citizen.
That is where the internal market went so badly wrong. It involved the creation not only of a divisive two-tier health service, but of a culture that was alien to most people's wishes for and expectations of the NHS. It is not long ago that we discussed GP fundholding and purchaser-provider splits. We have forgotten that, and we have come along way in a relatively short time, although there is still a way to go.
Foremost among expectations are openness and transparency. The inquiries into Stobhill and Stracathro spring to mind. Regrettably—and as Margaret Jamieson said—the problems there are not isolated incidents. They demonstrate that more work is required to ensure that health boards become more accountable. There is a democratic deficit.
North Ayrshire Council has set up a consultative health forum consisting of council members and officers, parliamentarians and chairs and chief executives of the local health authorities. Although it is a purely consultative body, the forum allows elected representatives to discuss constituents' concerns with health managers. It is certainly a step forward in community involvement. If local authorities are to drive forward the community planning agenda, clear opportunities will arise from such forums, but it would be a mistake to view accountability as relevant only in macro policy terms. Decisions about individuals are just as vital and require just as much transparency and accountability.
This morning, the minister spoke about too much bureaucracy and about fractured accountability. Sometimes, it is the little things that count for patients, including cleanliness on the ward and in the toilets; having someone to help with eating at meal times; and having easy-to-understand information. In all those matters, we must listen to the patients' voice.
Ninety-five per cent of GPs do a terrific job and act as a linchpin in the primary care sector, but it is a matter of concern that GPs can—and occasionally do—remove patients from their lists without being obliged to give any reason. No one would deny GPs the right to remove patients from their lists when a relationship has broken down, but the fact that they can do so without providing reasons often fosters mistrust of the service, usually among people who are socially excluded to some degree and who are, therefore, in most need of a positive relationship with the service. It would hardly be onerous to require GPs to give reasons for such decisions. It would cost nothing, but would improve accountability and individuals' relationships with the health service.
A record level of spend must be complemented by openness and transparency. The democratic deficit in the health service must be addressed.
I agree with the minister that we require this debate in advance of the publication of the Scottish health plan. The Conservative party has no problem with the motion or with Nicola Sturgeon's amendment. After three years of Labour Government in Britain, the health service is a basket case. After 18 months of Labour control in Scotland, with all the reforms and reviews, we have a patient who, if not yet ready for autopsy, is still not out of the critical care ward.
The Minister for Health and Community Care mentioned the white paper "Designed to Care", which amended trust duties to make trust chiefs accountable for the quality of care provided. That was laudable, but it added to the layers of bureaucracy and confusion in the health sector. Nothing was done to define leadership. I may not be the expert on the health service that colleagues in the chamber profess to be, but from my time in the army and in industry I know that leadership is not rocket science. Three basic things are necessary to make progress in any organisation: clear, unequivocal instruction on what the task is; a means of identifying the objectives; and measures to establish whether the objectives have been met and the task is complete.
The failure of leadership in the NHS is illustrated by what happened in the Tayside Health Board, as Andrew Welsh and I well know. A ministerial task force had to be sent in to sort out the mess. It identified confusion, a morass of cross-cutting responsibilities, failures to recognise problems in time, the trust's inability to work with the board and impotence and frustration in a health board that had responsibility of disbursing funds but no automatic right to check or monitor the use of those funds.
We should welcome ministers' recognition that the NHS in Scotland needs a hierarchy that is responsive to local needs yet retains a system to allow not only the identification at an early stage of incompetence, mismanagement or sheer cussedness but the recognition and promotion of good practice.
The setting up of the Scottish Parliament, as so many people have said, must surely allow for the many layers of bureaucracy to be stripped back and for decisions to be devolved to a local level. I thank George Lyon—who has left the chamber—for articulating Tory policy so well. Usually, when Hugh Henry sounds reasonable I realise that it is time for me to up my medication, but he is right—the NHS must be responsive to the needs of clients, not to politicians or civil servants. Again, Tayside provides an example in the acute services review's failure adequately to consult the local community and patients, leading to the incorrect—at least, I hope it is incorrect—impression that Perth royal infirmary is being closed or run down by stealth.
In his summing up, the Deputy Minister for Health and Community Care should tell us clearly what lies outwith ministerial control and what the responsibilities of civil servants in the NHS are. He should tell us in what circumstances ministers will take responsibility—if, indeed, there are any. We do not want to see put in place governance that allows ministers to duck responsibility by passing the parcel to boards, to trusts, to local health care co-operatives and back again.
So often, debates such as this are fig leaves to cover ministerial embarrassments or, in this case, past failures to act. Autumn is here, the fig leaves are falling and what is revealed is not a pretty sight.
I congratulate Malcolm Chisholm on his new role. I also congratulate the Minister for Health and Community Care for bringing the motion before the Parliament. It demonstrates her clear commitment to identifying a way forward that we can all sign up to. I also agree with what Margaret Smith, Hugh Henry, George Lyon, Margaret Jamieson and Irene Oldfather have said this morning.
Many of the challenges that face us stem from the overlapping circles of health services and local government, but the community planning that Frank McAveety mentioned this morning is not enough. We need more fundamental change. The people whom I represent in Fife have a clear focus on accountability, which they believe is the key to so much. It costs £3.5 million to run Fife Health Board, yet the board and the trust still do not reflect the issues that local people face. Nearly a thousand elderly and frail people in Fife await assessment for occupational therapy—that is only one illustration of that point.
When the Scottish Parliament was established, local government feared that the Parliament would suck up its powers. The Minister for Health and Community Care has an opportunity to be bold and radical, and I believe that she is capable of being just that. What we see as the solution in Fife may not be the way forward elsewhere; in Fife, the boundaries of the health bodies, the council and the emergency services match, but that is not the case elsewhere.
More than a year ago, Fife trades council called for Fife Health Board to be transferred to Fife Council. I believe that my colleagues in Fife Council could demonstrate to the minister that they could undertake the duties of the health board and, at the same time, achieve a commitment to minimal restructuring for employees in the health services. There is no doubt that NHS workers will be very anxious about such a suggestion; our challenge will be to reassure them that any resulting changes would cause minimal disruption.
Having experienced the 1996 restructuring of local government, I know how vital it is to ensure that staff in public services are valued and not demoralised by uncertainty. Above all, they must have the resources to do their work and to deliver the best possible service.
I agreed with a number of things that Nicola Sturgeon said this morning. Local people need to feel that they can influence and shape their local health services. The most frequent problem that I confront in my area is the inability of the professionals at the sharp end to deliver the services that their patients need. That stems from decision making at health board level, where barriers to the resolution of issues are continually presented. An example of extraordinary delay and prevarication in Fife Health Board was the issue of GP practice nurses. It took me a year to get a conclusive response, but that response still does not resolve the issue.
Fife Health Board's resource planning continues to result in health visitors and nurses in the village of Ballingry having to raise charity funding for aids and adaptations. Fife Acute Hospitals NHS Trust continues to be a law unto itself. Earlier this year, it made a decision to impose car parking charges at hospitals in Kirkcaldy and Dunfermline. Despite a petition of 90,000 signatures to the Scottish Parliament, and despite joint press releases from Fife MSPs, MPs and councillors, the acute trust has set its face and is determined to proceed. Where is the community planning in that? Where is the partnership with transport officials?
Denmark is just one example among our European partners of a country where the health services are in the hands of the local authorities. They have demonstrated how accountability can work. Will the Parliament encourage the Health and Community Care Committee to send a delegation to investigate how giving responsibility to local health authorities has led, in a clear and accountable way, to the beneficial involvement of local people?
Accountability and public consultation are important issues. I am sure that all of us in the chamber agree that the structures of NHS decision making are outdated, outmoded and in need of urgent review. Eighteen months ago, some parliamentary colleagues and I formed an unofficial cross-party group to look into the future of hospital services in south Glasgow. We did so because we had been presented with plans by the South Glasgow University Hospitals NHS Trust and Greater Glasgow Health Board to restructure hospital services in south Glasgow. Those plans were virtually cut and dried, and were comprehensively rejected by community groups, NHS staff and service users.
My parliamentary colleagues and I persuaded the board and the trust to reconsider the plan prior to the launch of their statutory consultation. During that period, and into the consultation, we met umpteen groups—ranging from hospital staff associations to the ambulance service to the Minister for Health and Community Care herself. All my MSP colleagues attended numerous public meetings across south Glasgow, taking soundings directly from constituents. The board extended the consultation period by 10 weeks, and the number of public meetings that it organised increased manyfold.
Once the consultation period was exhausted and the submissions had been delivered, it became clear that no cognisance whatever had been taken of the cross-party submission or of many others. The staff were ignored; the patients were ignored; and the community groups were ignored. To many, the consultation was a sham and an insult to those who took part. To the board and the trust, the consultation was a costly irritation, but one that did not deflect them one iota from the path that they had pursued prior to the exercise. To add insult to injury, the health board is now selling its plans via press advertisements costing tens of thousands of pounds that would otherwise be spent directly on services.
We need a response from boards and trusts that genuinely acknowledges the concerns of the public and professionals. The minister gave us hope when she spoke of her clear appetite for change. Is she aware that many decisions that have been made before any effective consultation had taken place are ultimately down to her department? For example, at Glasgow royal infirmary, despite total opposition from medical and nursing staff who believe that the merger will prove disastrous for patients, staff have been told that to access £50,000 to £60,000 to address winter pressures, a specialist head injury unit must merge with two medical wards. No one was consulted; staff were presented with a fait accompli. Why? The board said that without the merger, the Executive would not release money for winter pressures. The board said that
"following announcement of additional monies made available by the Scottish Health Department to address winter pressures, the Trust prepared a bid to secure almost £1 million additional funding . . . A key element of this bid outlines a proposal to integrate the head injury service, currently provided at Ward 29 with the Acute Medical Receiving service in Wards 4 and 5".
Staff believe that that blackmail will result in a loss of staff specialisms, a mismatch between patient needs and services and, ultimately, a loss of experienced staff who believe that their new working conditions will be intolerable.
Fundamental change to the way in which NHS staff work at the coalface must be preceded by real consultation if morale is to be maintained and service delivery improved. We must democratise the NHS.
I ask all concluding speakers to trim a few paragraphs from their speeches if at all possible.
Devolution offers us an opportunity to reshape the national health service in Scotland, to suit our own needs. However, such vocabulary—"reshape"—must raise hairs on the necks of all who work in the NHS. They have been through organisation, reorganisation, purchaser-provider split and reconfiguration. Just saying all that demonstrates the forces of fragmentation that have acted upon the health service over the past decade or so.
Staff have been working away in hospitals, health centres and communities while the management structure has been formed, broken up and reformed above and around them. It is probably fair to say that most management effort over those times went into managing change, rather than services. Each change has left a trail of debris and a huge and complex organisation has become littered with the remnants of each succeeding structure. Several members have highlighted that problem.
The health service will always be huge and complex, but we must accept the current structure and work within it, focusing on service delivery and staff welfare. It may be heresy to say so, but sometimes I think that structures are irrelevant. People will find ways in which to work within any structure. People can, do, and want to work together. Our job is to give those people the tools to do the job and then step back and let them do it.
Recently, I spoke to a health manager who had spent months trying to work with his opposite number in social work to set up protocols for joint working in a certain locality for the dozen staff involved. In the end, they made a leap of faith: they got the staff together, told them what they wanted and asked them to go and do it and to draw up the protocols as they went along. It worked. There is a lot to be learned from that. John Scott raised that issue. If we give people responsibility and let them get on with it, they will rise to the challenge.
I want to pick up on one or two issues that have been raised by members. Nicola Sturgeon talked about the SNP idea of a national health service commission with a strategic role, which would call into question the role and function of health boards. Various people talked about health boards and highlighted bad examples. However, just because there are bad examples, that does not mean that the role and function of health boards is wrong. We need a local strategic focus and health boards provide that. Whether such bodies should be quangos is another argument, but I am sure that someone must carry out that job at that level.
Nicola Sturgeon talked about additional money going into direct patient care. However, I want to sound a note of caution. We should not forget the health service staff. There are shortages of consultants, specialists, doctors, nurses, ward cleaners and porters; those staff that we have are working seriously long hours. Sorting that out will soak up a lot of resources. That money will not go into direct patient care, but will undoubtedly lead to better patient care.
Mary Scanlon talked about the "deep-rooted, elitist hierarchy" in the NHS. That was an accurate description, but that culture has been eroded. Nurses and other health professionals, such as pharmacists and professionals allied to medicine, are being given higher status and more responsibility.
Several members mentioned coterminosity. All that I have to say about that is that the boundary commission made a right sotter, but as it is an independent body there is nothing that we can do about it.
There was talk about setting priorities and objectives and tying those to budgets. Community care was never properly funded and there were complaints about councils and their failure to deliver on their health responsibilities. That is true to a point, but we should recognise that they were making bricks without straw. We must recognise that the health responsibilities of councils are broad—not just direct health services, but good health, sport and the arts. I disagree with Mary Scanlon: trees are important.
SIGN, CRAG, NICE and so on all do different and complementary jobs. That is fine, so long as everyone knows what they are doing and sticks to their brief.
Budgets and their scrutiny is a Parliament-wide problem, and we have to crack it, not just for health budgets, but for all others.
We come back to patients, who are the root of the issue. They need an easy passage through the system. They need involvement in their own health care, and involvement in decision making about how services are delivered and the services that they want. To achieve that, we need to give them good information, for example the SIGN guidelines. If we implement our equality strategy, that will get better.
I welcome today's debate, but having served on two Government advisory committees on health in a past life, I wonder about the ability of the civil service and the minister to rewrite the book between now and next month. The minister made a brave statement about comments that are made today being pulled into the thinking, but I find it incredible that after three years of relative inactivity, we will make it all happen in a month.
Many good comments have been made today, and despite the fact that there have been woolly proposals, members have contributed in a meaningful way. I still have a few questions about the approach to the debate. There is a lot of talk about management change, but the fact is that the NHS is not a structure but an organism. If that is thought through, it will be realised how the service fluctuates, moves, grows, develops and shrinks in different parts of the country. That is a new way of looking at the NHS that is not too stylised.
We have far too many layers—comments such as that have come from members across the chamber—but if that is the case, why are we not talking about the layers? There was little mention, and none from the minister, of the potential role of local health councils as spokesmen for users and communities. I would like that role to be beefed up and the minister to introduce decent proposals. Another question is, if the internal market failed, why have so many problems arisen only in the past two years?
Two years ago at my party's conference, I had the pleasure of delivering the basis of our proposed structures for the health service. Then as now, we did not see the need to retain health boards. They served a purpose at one time, but that time has come to an end. If we are to be radical, we can start with that proposal. We want community health trusts that take in all aspects of primary care, community hospitals and mental health. We would push—others, apart from Helen Eadie, also hinted at this—for the transfer from local government of health-related care provisions into primary care, so that we get focused, hands-on, single-point-of-entry treatment and support systems. The public are looking for such clarity.
No mention was made of how the minister intends to be accountable, other than in the chamber, but there are many questions to be asked. Day after day, in answer to parliamentary questions, we get answers saying that the information is not held centrally. That cannot go on. If the minister is to make decisions, she must have the facts at the centre. If that means having a central statistical unit to provide her with trend analysis, that is what she must establish. It would be money well spent.
John Scott mentioned the clinical governance document, which I thought we were going to talk about today, but obviously we are not. Much of what is in that document is bureaucratic and needs to be put into plainspeak so that people can identify where things are going.
There was a lot of talk of postcode prescribing, but there is a solution to that. Health board money could be top-sliced and put in a central fund for which areas could bid, because clusters of conditions and treatments are not uniformly spread across Scotland. Every trust that I have spoken to has said that the issue must be addressed. If a trust has a lot of multiple sclerosis sufferers, who receive expensive treatment, and clusters of cancer and other conditions, disproportionate calls will be made on that trust's budget. Postcode prescribing has been talked about in the health service, but I have not heard the minister address it; our new deputy minister may do so when he winds up.
Everyone has talked about morale. GPs are saying that after the pain of moving to LHCCs, they see no gain. There is just pain—there are no new resources, no promises have been kept, and communications have broken down. The Executive must convince GPs that they can live with, and operate under, the Executive's proposals for them with confidence.
Membership of health boards has been discussed. The quality of the members is more important than how they are appointed. Board members give up their time, are paid little and invest much good effort.
Time is restricted, so I will not go into some of the finer detail. We live in a world of economic reality, and all speakers have called for transparency and focus. The big issue is whether we devolve or centralise responsibility and design. Opposition parties and the junior partners in the coalition have expressed a fair amount of warmth for early resolution of that issue.
Patient ownership of health care, shared by those who deliver the service, is the way forward. That will provide the democracy that we need and will improve morale. Leadership from the Minister for Health and Community Care is the key to building faith and confidence in our health service. I pray that the minister means it for once when she says that she will listen before she writes and publishes the document.
I join the long queue to welcome Malcolm Chisholm to his first debate as Deputy Minister for Health and Community Care. I will enjoy sparring with him. I also welcome the tone of the debate. However, we should beware that consensus does not become an excuse for inaction. In December 1999, we agreed that accountability was a problem. In March, we talked about accountability again. Now, in November, we agree again that accountability is a problem and needs to be improved. It is time to stop talking, to publish the health plan and to get on with making the required changes.
Financial transparency is crucial. We need to know where the pounds are going and whether they are being spent where they are meant to be. Margaret Smith talked about the £26 million from the tobacco tax. What difference is that making? Margaret Jamieson talked about Ayrshire and Arran Health Board and made the point well that answers cannot be provided locally to questions about where money is being spent. In that case, the health board was spending money where it was not supposed to be spent. Those issues must be addressed.
Many members talked about public accountability, which must involve visibility. Procedures must be transparent and we must stop information being shrouded in secrecy. We must also assess some of the announcements that have been made about accountability.
We should find out whether there has been any improvement in the representation on boards. What progress has been made? Do the health boards represent a wider pool of people? The local partnership forums were supposed to address many of the problems of accountability—what has happened to them? The patients project is supposed to improve the way in which the NHS communicates with patients and their carers and families. We talked about that in December—what has been achieved to date? We need answers to those questions today.
Consultation will be a key issue; it should be more than a formality that involves decisions being made after a sham of consultation has been carried out. Andrew Welsh made a good point about the problems at Tayside Health Board. We need to improve the levels of openness and accountability—patients deserve that and have a right to expect it.
I note Susan Deacon's caution on the structural issues. She said that we do not want the health service to face yet another major restructure. However, I echo George Lyon's point that we must do something about the layer upon layer of bureaucracy and quangos. I reiterate Nicola Sturgeon's points on the need to have a bit of ambition and vision—we hope to see that in the health plan.
I hope that the Deputy Minister for Health and Community Care will accept that the SNP amendment is a genuine attempt to strengthen the motion by adding to it public and staff involvement and a recognition that change must be resourced adequately. The issue of resources is important—change must be resourced adequately if it is to be successful.
We must also remember the points made by Hugh Henry about the language that is used sometimes—we, too, may be guilty of talking in tongues in the chamber. Hugh's comments about renationalising the health service will stay with me after the debate. He was absolutely right, because the public want a health service that has them at its heart. They want a health service that gives patients the No 1 priority and that ends postcode prescribing, so that it does not matter where in Scotland one lives. They want a truly national health service.
We have heard about the problems that are caused by out-of-date and inadequate equipment and by waiting times—depending where one lives, one's cancer may not be treated in time. We have heard from many people throughout Scotland about the need for clean wards, which is a basic point. When we talk about the NHS, we should remember the people's priorities.
We want the health plan to be issued before the Christmas recess and I hope that the Deputy Minister for Health and Community Care will give us a commitment to hold a full debate on the plan when it is published.
I thank Shona Robison for taking less than her allotted time.
I thank the members who have welcomed me back to the front bench. In particular, I thank Margaret Smith for her reference to the Health and Community Care Committee's attempts to knock me into shape, although the committee has been as successful in those attempts as others have been.
I acknowledge the great contribution made by the Health and Community Care Committee to the debate on governance and accountability. In fact, the issues that we have debated today have been raised over a long time by not only the Health and Community Care Committee but by staff in the health service, by patients, by managers and by members in the chamber. It was slightly odd, therefore, that Nicola Sturgeon spent the first three minutes of her speech asking why we were debating those issues.
Having said that, I welcome the constructive comments made by Nicola Sturgeon and Shona Robison. I assure them that the health plan will address many of the issues that they—and many other members—raised today. I reassure them that the plan is on track and that an announcement will be made to Parliament before Christmas, preceded by a presentation to the Health and Community Care Committee.
Shona Robison said that the issues we are debating today were raised a year ago, but we should remind ourselves that there has been massive consultation on the health plan and that many working groups have worked on it over many months. For those reasons, although we are sympathetic to the SNP amendment, we believe that its wording is slightly misleading, given the amount of consultation that has taken place. It is important that we progress the immediate changes without formal consultation, although it is clear that all partners will be fully involved in the longer-term plans.
We agree with many of the comments made by Nicola Sturgeon, many of which had been made already by Susan Deacon. In particular, Nicola Sturgeon called for us not to shy away from more radical restructuring. In Susan Deacon's speech, which members will be able to find and check in the Official Report, she explained how the health plan would pursue that important, long-term piece of work.
I also agree with many of the points made by Mary Scanlon in the debate. In particular, there needs to be more clarity on priorities. That is something that the health plan will address. I thought that Mary Scanlon was a little grudging about the considerable extra resources—more than £100 million—that were announced by Susan Deacon at the beginning of October for home care and other related services. That extra funding will address many of the problems to which Mary Scanlon referred. Those moneys are being given to local authorities on a new basis in terms of agreed outcomes. That is something that we should all welcome.
Today's debate has considered the problems that we have at the moment and has dealt with the general principles and policy objectives that will help to address those problems. I will not reiterate those problems, but I shall repeat briefly that current problems relate to the complexity of the system, ambiguity over where responsibility lies, blockages, slow decision making and residual competitive behaviour. Our starting point must be to say that how the NHS is structured matters less than how effectively it performs its principal functions. However, process of decision making is critical to that effectiveness.
I appreciate the fact that the additional money that was allocated to local authorities is being audittrailed and is based on clinical outcomes, such as how many people are being given home care. Does the minister agree that, on the basis of experience, all money that goes to local authorities should consistently be audittrailed and based on clinical outcomes?
We have made an important development in terms of the new money and we have a lot of information about how local authority money is spent at the moment. We do not want to get too tied up in audit trails, but we want to emphasise the importance of agreed outcomes.
I shall move on to deal with governance and accountability. Certain key themes and principles have emerged in relation to governance. First, the national health service is a national service. Trusts and health boards are the NHS and I welcome the recent submission from the Scottish Association of Health Councils, which pointed out that trusts and health boards must be more clearly branded as the NHS.
A second theme that has emerged is that effective, integrated decision making is key to improvement. Mary Scanlon said that David Mundell had referred to the consolidation of trusts and boards. I welcome Margaret Jamieson's reference to there being one plan, and I note and welcome Hugh Henry's words—echoed by Tommy Sheridan and Shona Robison—about the renationalisation of the national health service. I am, of course, far too new Labour to use such a word, but it has been a hallmark of the debate. Susan Deacon may live to regret that one of her good lines has been stolen rather prematurely.
Another key theme has been the importance of greater clarity about roles and responsibilities, which includes the health department setting the strategic policy agenda. The corollary of that is strong local systems, and we heard the evidence from the MORI patient survey that found that people do not feel that they are involved in decision making. Patients and the public are clearly at the heart of our developing agenda for the national health service.
I welcome the practical points that Irene Oldfather made about matters such as cleanliness in hospitals. I reaffirm our commitment to the modernisation of local health councils, which clearly have an important continuing role to play. I also emphasise the importance that we attach to patient information, which was mentioned by many speakers.
It is not just the patients and the public who matter. Mary Scanlon, Margaret Jamieson and Tommy Sheridan all mentioned the importance of the staff. Work has begun in the Scottish partnership forum to improve staff involvement.
Several speakers asked for a progress report on the patients project. Can the minister provide such a report now?
One of the major themes of the health plan will be the whole patient and public involvement agenda, and more will be said about that then.
The last partners, but by no means the least, will be the local authorities, which Frank McAveety mentioned.
On accountability, the important general principle that has emerged today is whole-systems accountability. More specifically, we need greater clarity about lines of accountability—who is accountable to whom, and how. Accountability needs to be both upwards and outwards—or downwards, as Nicola Sturgeon put it. Again, local authorities have a role in ensuring that.
Key to our proposals on accountability is the need for a clear performance assessment framework. We want a performance assessment process that focuses on patients—on the people who use the service and their experience of it. We want a framework that focuses on outcomes, not inputs. As many members have said, money is important, and it would be irresponsible to suggest that the largest public sector body in Scotland can afford to be anything other than financially sound. However, our measures of success must also accommodate people's experience of the service. This must be about achieving quality outcomes.
We have consulted widely about the issues that I have outlined and others, and they will be dealt with in the Scottish health plan. We will continue to consult until we put the plan to print. However, the process will not stop there. The plan will be a staging post, not an end point. It will signal the direction of travel for years to come. We recognise that there is more to be done and will continue to involve those who will be affected by the plan: the public, patients, carers, staff and public and voluntary organisations.
Today we have talked much about the NHS, local health services and local systems. However, we must always remember that the NHS does not exist in isolation, but must interact with others, not least with local authorities around Scotland. Increasingly, our work on health is interrelated with the work of other public and voluntary organisations and with the Executive's policies on housing, education, social justice and social inclusion. We recognise that, and also recognise the fact that we must do more to work with everyone who is involved in those and other areas. We regard that as fundamental to the health improvements that we want to achieve.
I know that today's messages will be welcomed by everyone who has a genuine interest in improving the health of our people and the health service that they receive. I say to all members present, and to people who are listening elsewhere, that the status quo is not an option. The Executive recognises the strength of feeling around this issue and the desire for change. Susan Deacon and I also want change. However, we must resist the temptation to go for wholesale structural change that will distract attention from the real priority—improving health and people's experience of their health service.
Today marks the beginning of a process of moving forward. I want us to move forward together. We know that there are already many good examples of joint working and integrated planning. We want those to become the norm across the NHS in Scotland. Partnership working and joint working are necessities if we are to deliver the truly seamless care that the people of Scotland have a right to expect. This is not about structural upheaval, but about improving the health of the people of Scotland and achieving quality patient care for all.