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Chamber and committees

Meeting of the Parliament (Hybrid) [Draft]

Meeting date: Thursday, November 10, 2022

Agenda: General Question Time, First Minister’s Question Time, Point of Order, Mental Health (Workplace Stigma), Portfolio Question Time, Alternative Pathways to Primary Care, Parliamentary Bureau Motion, Decision Time


Alternative Pathways to Primary Care

The Deputy Presiding Officer (Annabelle Ewing)

The next item of business is a debate on motion S6M-06702, in the name of Gillian Martin, on behalf of the Health, Social Care and Sport Committee, on its inquiry into alternative pathways to primary care. I invite members who wish to speak in the debate to press their request-to-speak button.


Gillian Martin (Aberdeenshire East) (SNP)

As the convener of the Health, Social Care and Sport Committee, I am pleased to open the debate on the committee’s inquiry into alternative pathways to primary care. I thank everyone who engaged with the inquiry, whether that was through the call for views, the public survey or the formal and informal evidence sessions. Being able to engage with so many different people in so many different ways, as the committee always strives to do, has been invaluable in helping us to reach our final recommendations.

Primary care services are the front door of the national health service. When a person seeks healthcare, their first point of contact has traditionally been a general practitioner. However, our inquiry focused on other routes to accessing healthcare in the community, which, for the purposes of our inquiry and report, we termed “alternative pathways”. Those various pathways include seeing a different and, often, specialist health practitioner—for example, a physiotherapist, urgent care practitioner or nurse—who is located in the GP practice or the local community.

A patient’s route to treatment might be through social prescribing, which aims to improve health and wellbeing through activities such as talking therapy groups, social and physical activity groups that are run by the third sector, and volunteering. There is also the option to use helplines or online services to access additional information or therapy. There are pathways on our high streets, where Government-funded specialist healthcare is offered via pharmacists, podiatrists, optometrists and hearing services, for example.

The Government’s vision is that people who need care are informed, empowered and able to access the right professional at the right time. The committee supports the primary care reforms and the Scottish Government’s vision to widen the primary care pathway. However, through our inquiry, we found that there are a number of obstacles to achieving that vision. Those include limited public understanding of primary care reform and what it means for the public; the workforce and capacity issues that non-GP primary care practitioners face; poor signposting to alternative pathways, including inaccurate information about locally available community services; digital exclusion of certain people in our society and variable availability of digital health and care services; and patient record systems that do not align with one another to enable shared data that is easily accessible by multiple healthcare professionals working with shared patients.

Evidence that was submitted to the inquiry suggests that primary care reform and the reasons for it are still not well understood by the public. Many people still expect to be able to see their GP for every health issue, no matter how minor. Limited public awareness of primary care reform seems to be the main cause of that. When they are presented with the idea of alternative pathways, people often say that they feel fobbed off when, in fact, they have been directed to the right type of care. One witness told the committee that there has been a

“failure in getting over to the public that general practice is changing, why it is changing, why it needs to change and what will be put in place to ensure that healthcare needs are fully taken account of.”—[Official Report, Health, Social Care and Sport Committee, 8 March 2022; c 5.]

It is imperative that the public understand the reasons behind primary care reform. Rather than preventing them from seeing their GP, primary care reform is about making sure that they get quick and easy access to the best person to support their needs. Until that is understood, there will continue to be issues with the public making proper use of alternative pathways.

The Cabinet Secretary for Health and Social Care told us that the Scottish Government has undertaken public information work to inform people about primary care reform. Although the committee welcomes that, we believe that more must be done to increase the general public’s understanding of such reform and what it means for them. We recommend that the Scottish Government implement a co-ordinated communications plan to look at where such awareness is lacking and to address it. That should include targeted national and local elements and be accompanied by a robust methodology for monitoring and evaluation of those communication efforts.

The Scottish Government’s intention is that the shift to multidisciplinary working will reduce pressures on services and ensure improved outcomes for patients, while freeing up GPs to spend more time with patients with acute conditions or urgent health concerns who need their expertise. That being the case, a key aim of our inquiry was to establish the extent to which primary healthcare professionals other than GPs have the capacity to take on more patients and accommodate an increase in referrals.

Refocusing GPs to take on an expert medical generalist role is contingent on the recruitment of a range of practitioners into multidisciplinary teams, or MDTs, as I will refer to them from now on. Before the start of the Covid-19 pandemic, Audit Scotland reported that health and social care partnerships were having difficulties in recruiting practitioners to, and retaining them within, GP practice MDTs. The inquiry also highlighted a shortage of available capacity in non-GP primary healthcare professions, including pharmacy, audiology and psychiatry, although some bodies, such as Optometry Scotland, claimed that they had untapped capacity and the ability to take on more referrals. We did not hear from representatives of every discipline, so I wonder how many more bodies out there are in the same position as Optometry Scotland.

The committee has concerns that, in the short term, workforce constraints and recruitment delays will limit the capacity of non-GP professions to take on increased referrals. There is a danger that, if those referrals are not successful, patients might not want to use alternative pathways in the future and will revert back to their GP. The committee firmly believes that better recruitment and retention of professionals is crucial to the success of alternative pathways, notwithstanding the workforce pressures that we all know about.

Accelerated training and recruitment to increase workforce capacity are essential. We must make known the varied career routes that exist to young people who express an interest in healthcare as early as secondary school.

I turn to what the committee has termed, for ease of reference, the single electronic patient record. Such a record has long been seen as having the potential to transform multidisciplinary team working and to give people consistent access to the best care by allowing seamless transition between services. Throughout our alternative pathways to primary care inquiry and other inquiries that we have undertaken, the committee has heard that access to data across different health specialities can be difficult, inconsistent and time consuming, which leads to frustration for practitioners and patients. There was broad agreement among many contributors to the inquiry on the need for better integration.

The cabinet secretary has said that work is already under way to produce a single electronic patient record, but it is incumbent on him and the Government to accelerate that work. Since the report was published, I have appeared at several round tables on the issue. We might need not a single record but a single interface that ties systems together, and we might need to calibrate our language around that. Practitioners should not have to log in to multiple systems that do not talk to one another, and patients should expect that the range of clinicians who treat them will be able to see the right information about the patient in front of them, so that they do not have to recount their story over and over to different people. A single interface could bring records together, and the commitment to that is most welcome.

I welcome the cabinet secretary’s response to our report and what he said about working together to address the challenges. I hope that, by carrying out the inquiry, we have shown that there is a live discussion about access to alternative pathways and the better use of those pathways. We must continue making reforms to make that process seamless for patients. I hope that that will enable us to achieve the better health outcomes that we all want primary care reform to deliver for the Scottish public.

I move,

That the Parliament notes the conclusions and recommendations contained in the Health, Social Care and Sport Committee’s 9th Report, 2022 (Session 6), Alternative pathways to primary care (SP Paper 201).

I remind members who wish to speak in the debate to check that they have pressed their request-to-speak button.


The Minister for Public Health, Women’s Health and Sport (Maree Todd)

As the public health minister, I welcome the opportunity to open this debate on alternative pathways to primary care. I commend the committee for its timely inquiry into a topic of such high importance and thank the many stakeholders and members of the public whose views informed the committee’s final report. My portfolio means that I am all too aware of the health challenges that Scotland faces. As the front door of the NHS, primary care, which sits in the heart of our communities, is at the forefront of our efforts to tackle those challenges.

Primary care has changed significantly in the past few years. Since 2018, we have committed more than £0.5 billion for employing many more healthcare professionals to work in multidisciplinary teams. There has been a major culture shift away from a model of care in which a doctor is often the first point of contact, to one in which patients benefit from access to a whole team of health professionals. In general practice, that means that an increasing number of patients receive the care that they need from pharmacists, advanced practitioner nurses, mental health workers, physiotherapists and community link workers. Through our reforms, we have recruited 3,220 of those professionals to work in primary care multidisciplinary teams since 2018. In the wider primary care system, more patients access the care and advice that they need from community pharmacists.

At the same time, we remain committed to increasing the number of GPs in Scotland by 800 by the end of 2027. We envisage a person-centred primary care system in which GPs occupy the role of expert medical generalist, supported by a multidisciplinary team that provides holistic care to patients. It is important to recognise the commitment from our skilled workforce that has made that culture change possible, so I welcome the committee’s recognition of the hard work that that has involved.

That fits into our wider reform agenda within primary care, and our aim of transforming the system to ensure that people are seeing the right professional at the right time. Reforms to improve patient experience are under way across Scotland. The new GP contract and the expansion of multidisciplinary teams in general practice include new or re-imagined roles such as community link workers or care navigators. At the centre of all of that work is a commitment to ensure that patients and their experience of primary care come first.

Are we are aware of how many full-time-equivalent GPs currently deliver primary care in the NHS? Are we aware of how many full-time-equivalent community link workers are currently working across Scotland?

Maree Todd

I can get that data for the member. I am sure that the cabinet secretary will include it in his summing up. I know that we have increased the number of GPs working in Scotland and that, as we have said many times, Scotland has more health professionals of all kinds per head of population than the other parts of the United Kingdom.

One of the most important innovations that we have seen in primary care—and one in which I am especially interested—is the move away from a purely medical model of care. We know that many of the forces that shape a person’s health and wellbeing issues are their social and economic circumstances. That is where community link workers in general practice and other social prescribing professionals in other community settings have played such a key role. Having specialist staff who can work with an individual to get to the heart of their experiences and then identify and help them to access through the system the community support, financial help or practical guidance that they need not only benefits that individual but helps to ensure that clinical staff are free to focus on cases that require a clinical approach.

The introduction of such workers was timely, as they played a truly invaluable role within their communities during the pandemic, and demonstrated admirable ability to adapt to a rapidly developing situation. I was pleased to see acknowledgement of their work not just from the committee but from several independent research and evaluation studies. We are extremely grateful for the efforts of our community link workers during a challenging time and will continue to support their work, which forms a key part of our recovery from the pandemic.

We have developed other primary care roles to help to guide patients through that complex system. Our care navigators are absolutely key in that regard. As front-of-house staff, they are often a patient’s first encounter with primary care. In recognition of the importance of their role, we are working to upskill our care navigators and to ensure that those changes are communicated to the public through the receptionist campaign that was launched earlier this year.

As well as the more varied workforce that has been developed, there are now more diverse pathways and methods to enable people to access care and support. Telephone consultations have long been part of general practice, and the pandemic has certainly increased their use. Other changes have arisen from digital innovations that were often accelerated by the pandemic. We are working to ensure that patients have as many user-friendly options to access support as possible. Increases in funding have allowed NHS 24 to move from being a predominantly out-of-hours service to one that operates 24/7. People can access telephone support through a number of pathways, including the mental health hub, the Police Scotland pathway for people in mental health distress, the wellbeing helpline and the urgent care pathway.

An increasing number of digital pathways is available to patients. We are continuing to roll out, which is a user-friendly website that provides practices with a consistent NHS website for patients to access up-to-date health information and which will support online prescription ordering. NHS Inform, which was established in collaboration with Public Health Scotland, has seen usage of up to 12 million site visits per month to access the up-to-date self-help advice and guidance that are on offer. That is a phenomenal resource. The experience of the pandemic increased many people’s familiarity with such digital pathways, and we are working to fill gaps in digital literacy to prevent any inequality of access.

I am mindful of the fact that not everyone will benefit equally from those changes. What for one person is a positive ability to choose the care that they feel they need might just feel to another like a confusing array of options, which might create anxiety for them or dissuade them from seeking the help that they need. We are also very aware of the need to avoid change that might unintentionally widen health inequalities.

Of course, new pathways to care and an expanded workforce have needed considerable investment. The key enabler for multidisciplinary teams has been the Scottish Government’s primary care improvement fund, which has grown continuously since its introduction in 2018. To embed the progress that has been made and to expand upon it we have increased its funding to a new record level of £170 million for the year 2022-23, which will form a minimum budgeted position that will ensure continuity of funding going forward.

The committee’s report highlighted areas in which our reform agenda has delivered improvements for patients, as well as those in which we need to continue our collective efforts. I think that all of us are realistic that this winter will bring unprecedented challenges across the whole health and care system. However, those tests should not lessen our commitment to ensure that we are doing all that we can, with the resources at our disposal, to improve health outcomes through offering patients alternative routes to the care that they need.

I welcome the debate as an opportunity for us to reaffirm our commitment to ensuring that patients and their experience sit at the heart of primary care and that primary care sits at the heart of our health system.


Sandesh Gulhane (Glasgow) (Con)

Primary care is the backbone of the NHS, and it is at breaking point. With increasing demands and limited capacity, it is in a perpetual extreme winter. The expectations that are being placed on GPs and their practices are causing burn-out and demoralisation and are, ultimately, forcing doctors to leave a profession that they love.

This is a typical Monday in a GP surgery. I am in for 8 am and start with paperwork—and, believe me, there is a lot to plough through. In the background, I hear the volley of ringing phones and our fantastic surgery staff handling call after call—and, indeed, dealing with a lot of abuse, too. They are really under the cosh.

By about 8.30, I have started to see patients. Some on a long waiting list for surgery will be struggling in pain, while others will have chronic conditions like chronic obstructive pulmonary disease or diabetes. There might be a happy mum-to-be, but there might also be patients who need to be seen by a specialist in hospital immediately. GPs cannot afford to miss a sign that someone is going into crisis.

By lunch, I have had 30 patient contacts. After stretching my legs at a house call and catching some fresh air, I go back to the surgery, where, over the afternoon, I will usually have another 25 patient contacts. During the day, I will be checking blood results from the laboratory and overseeing other clinical staff including advanced nurse practitioners, allied health professionals and paramedics. There will be questions from pharmacists—and what about repeat prescriptions? In Scotland, all practices—or at least the vast majority—have an online request system, but unfortunately each and every prescription must be wet-signed. In other words, we must sign prescriptions with a pen, and I do about 300 in a day.

That is a typical day for GPs across our country, so alternative pathways to primary care provide a vital way of alleviating the burden on overstretched GPs and other healthcare professionals. I appreciate that we are focusing on primary care pathways today, but we should be mindful of the wider NHS that GP practices are part of. Primary care cannot and does not function in isolation.

The British Medical Association Scotland has made it clear that the NHS is struggling under workload pressures and workforce issues. Pressures that doctors were used to dealing with in the winter are now affecting the NHS all year round, with staff now feeling as if they are working in a perpetual winter. As for general staff welfare, we need only consider surveys by the Medical and Dental Defence Union of Scotland. According to those surveys, 78 per cent of junior doctors in Scotland have experienced burn-out; 42 per cent say that a lack of access to nutritious food at work is a contributing factor; and 66 per cent report that they fear patient safety is at risk when hungry and tired. That is really worrying, and it is symptomatic of a management culture that does not prioritise front-line healthcare workers.

Dr Andrew Buist, chair of the BMA’s Scottish GP committee, has said:

“Failure to support general practice now could have dire consequences for patient care across the country this winter.”

He goes on to say that the Scottish Government

“pledged a £30 million sustainability support package for general practice, to be paid in two instalments.”

The trouble is that, last month, the BMA was informed that the second £15 million “was being cut” to £10 million. Dr Buist says:

“That announcement came shortly after more than £50 million intended to support the development of health board teams within GP practices—-such as pharmacists, nurses, physiotherapists and mental health specialists—was withdrawn.”

As for alternative pathways to primary care, we need to be frank and ask whether we are doing enough to provide and communicate alternatives to GPs as the first port of call. Let us consider high street optometrists, who are well equipped with highly-specialised equipment to monitor and treat eye issues. However, a lack of funding is a barrier to these high street specialists acting as an alternative pathway. According to Optometry Scotland, the sector would, with additional funding, be able to offer an enhanced range of services and thereby ease pressures not just on general practice but on secondary care.

Then there are link workers. Glasgow health and social care partnership has said that the recruitment of community link workers is stymied by a lack of funding.

On social prescribing, Alison Leitch of the Scottish Social Prescribing Network has said that a lack of leadership in Scotland is holding social prescribing back. She said:

“no one, sadly, is taking charge of social prescribing. That is where Scotland falls down. In England, there is a head of social prescribing in the NHS; in Wales, that is dealt with through public health.”—[Official Report, Health, Social Care and Sport Committee, 22 March 2022; c 9.]

The Scottish Government is aware of that problem.

On dentistry, by cutting the funding multiplier that is paid to dentists, the cabinet secretary is presiding over the death of NHS dentistry in Scotland. In August, the BBC reported that, in Scotland, 82 per cent of NHS dental practices are now not accepting any new adult patients and that 79 per cent are not accepting new child patients.

On communication, the Scottish Government talks about promoting alternative pathways such as going directly to opticians, physiotherapists, podiatrists and pharmacists for support and even treatment, but the public are largely in the dark about that. According to The Royal Pharmaceutical Society, there is a lack of public awareness among patients about using alternative pathways. There has been no meaningful national publicity around changes to the GP practice teams and the roles of different professionals within the team. People become aware of that only when they are directed to the pharmacist, for example, as part of routine contact.

The Scottish Conservatives want to work constructively on alternative pathways and get them flowing. We would invest 11 per cent of the overall NHS budget in general practice by the end of this parliamentary session. We would also increase the number of training places to deliver the 800 more GPs by 2027 that we were promised, and we would ensure that all GPs are supported by a multidisciplinary team.

Emma Harper (South Scotland) (SNP)

Some of what the member is saying is interesting, and some of it is in the report. However, it seems as if what he is proposing is not what the report was about. Could he provide some clarity about the part of the report that he is referring to?

Sandesh Gulhane

I am referring to the professionals whom I am in contact with every day. This debate is about alternative pathways; it is not purely about the report that was produced.

If we increased the budget for GPs in the way that I outlined, that would enable GPs to offer longer appointments to those who need them.

We want alternative pathways to be rolled out in order to ease the pressure on GPs. We would train more independent prescribers to enable pharmacists to treat a wider range of common conditions, and we want social prescribing to be embedded in primary care, including through the rolling out of community link workers and links to advice services more widely. For example, embedding citizens advice bureaux in primary care facilities makes a huge difference.

I draw members’ attention to my entry in the register of members’ interests, which states that I am a practising GP.


Carol Mochan (South Scotland) (Lab)

I take this opportunity to thank all my colleagues on the Health, Social Care and Sport Committee for the work that they put into the report. I am pleased to open the debate for Scottish Labour. My party fully supports the report and looks forward to seeing its recommendations coming to fruition.

There is a lot in the report that the Government must act on. If it fails to do so, it will let down many people who would benefit from the great reform that is outlined.

I am confident that we can, with the right approach and good will, take into account the testimony of experts and the public on matters as important as self-referral and patient records, and that we can, in doing so, make Scotland a real pioneer in championing alternative pathways to primary care.

A key takeaway from the report is that the Scottish Government has failed to explain and promote its vision for primary care and to say how it will adequately inform patients of how to access alternative pathways directly. That is something that the committee heard time and again from people who deal with patients day in and day out.

The narrative that is spun by the Government—that there is wide public awareness of reforms to primary care—is simply not true, as is backed up in the report. Few patients fully understand the self-referral process. That is, in large part, due to a failure to properly inform the public of the changes and of how they can access services and make sense of the arrangements. We must do better on those points.

From Dumfries to Thurso, the way in which people can self-refer varies significantly—from location to location and from category to category. We need to help people to understand the processes in their areas so that they can access the services that they need. For example, although the option to self-refer to pharmacists, opticians and dentists is reasonably well understood in many areas, there is far less public awareness of the option to self-refer to services including audiology and mental health services. Given that the mental health services backlog is growing day by day, it strikes me that changes in that area could be of great benefit to many people throughout Scotland who are struggling. It would not be especially costly to the public purse to help people to navigate the system for mental health wellbeing and support.

The lack of a single electronic patient record is, of course, key to all the blockages. We heard that time and again, and the committee convener referred to it. Single electronic patient records would streamline the process by which people are referred to, and self-refer to, the alternatives to primary care. That is probably the single recommendation that we heard most consistently during the creation of the report. Although there is no doubt that there are serious logistical barriers, they can be overcome, so we must do better on that. Until that issue is resolved, wider understanding and use of the pathways will be limited. That begs the question why that is not the Government’s top priority: it has to be. I ask the cabinet secretary to respond directly to that in his closing remarks.

The Government has made commitments on workforce numbers and on increasing capacity in primary care. Time and again, those commitments have not been met in any serious way. Therefore, it is perfectly understandable that services that deal with referrals and advice are often overwhelmed. Understaffing leads to an unfair perception of the services among the public. We heard that as we collected evidence on how the public interact with the people who provide the services—in particular, in the new pathways. We cannot expect a first-class health service when staff are overworked and overtired, and when the patients and service users who come through are not fully aware of how the service works.

I have no doubt that the prevailing economic climate makes life difficult for all aspects of our NHS—not least staffing. However, the cuts that were announced last week are not justified. Some £400 million was slashed from key health and social care budgets. The direct impact of that will be incredibly harmful for some of the most vulnerable people who are in need of care, and it will make work on what is in the report all the more difficult. It is remarkable to me that, on the same day as the Scottish Government launched an awareness campaign encouraging people to get the right care in the right place, Scottish National Party ministers cut the primary care budget by £65 million and the mental health budget by £38 million. The reality of those cuts to ordinary people will be devastating, and they will make it very difficult for people to do their job of building sustainable first-class services.

The Cabinet Secretary for Health and Social Care (Humza Yousaf)

I thank Carol Mochan for taking an intervention during what I think is a really helpful speech. If we have to mitigate £650 million of inflationary pressure and have to give a fair pay deal to NHS workers, but we do not reprofile money from somewhere else, where can we get the money from, in this financial year?

Carol Mochan

The cabinet secretary will know that I absolutely agree that one of the biggest challenges that we face in Scotland is the current climate of austerity from the Tory UK Government. However, we must have more honesty in Parliament about the SNP’s inaction and inability to produce a vision of how we can make changes happen. It is really important that the Government health team looks at what can be done, as opposed to constantly talking about what happens because of Westminster and the Tories. I want the SNP to have a vision and to talk about the things that it can do. I understand that there are inflationary pressures, but one of the biggest things that we could do, of course, is ensure that we get a Labour Government when we get the chance. I ask SNP members to help with that, if they get the chance, at all.

As I have said, Scottish Labour is committed to getting primary care right for patients and staff. I ask the Government to reconsider the cuts and to ensure that we can make headway with the report and the excellent outcomes that we could have from it in Scotland.


Willie Rennie (North East Fife) (LD)

I will come to the pretty impressive committee report, but we simply cannot ignore the context. I have never seen primary care in the state that it is in now. Patients call repeatedly day after day to get appointments. Doctors are under incredible strain and are often burned out. Many are leaving the profession or going part time, and practices are closing down. All that puts more strain on those who remain.

Even pharmacies are closing down. The ramifications for the rest of the NHS are evident, too, with ambulances queueing up outside hospitals, long waits at accident and emergency departments, long waits for treatment and even longer waits for mental health treatment.

On social care, there are thousands of people without care packages who are stuck at home or stuck in hospital, which also compounds the problem for the NHS. Now the nurses are on the verge of a strike: nurses never go on strike. That is how bad it has become. The situation is incredibly dark. The BMA talks of people being at breaking point, about burnout, about demoralisation and about departure.

Yes, the pandemic has had an impact. I agree with the health secretary on that, but the Government’s negligence and complacency over many years are far bigger factors.

Former NHS Scotland chief executive Paul Gray says that the problems have been building for years, since well before the pandemic. Let us remind ourselves of what he has said, which was that

“The current system was going to be overwhelmed regardless of Covid. The virus has simply brought the date of that event forward”.

The reasons for that, after 15 years of this Government, include inadequate reforms, poor workforce planning for the multidisciplinary team—

Will the member take an intervention?

Willie Rennie

I will not just now.

The reasons include refusing for years to recruit enough GPs, cutting the number of nurse training places, failing to eradicate delayed discharge, which the Government promised to do, by 2016—

Will the member give way?

Willie Rennie

The member should listen to this list. It is important.

The reasons include undervaluing of social care year after year after year, and delaying the mental health strategy and the spending that would be associated with it.

Action 15 of the mental health strategy committed £35 million for additional mental health workers in A and E departments, police custody suites and general practices, but ministers now cannot even tell us whether the target has been met. The explanation, in a parliamentary answer, is that the Government does not “hold the data”.

I will take an intervention from the minister.

Maree Todd

I wonder, as I listen to Willie Rennie’s litany of failures by the SNP Government, whether he has reflected, at all, on his party’s role in bringing in austerity when it went into government with the Tories in 2010? That Government brought us austerity, which, as we now all know—and academics have proved—has shortened the lives of people who live in Scotland.

Willie Rennie

We must pray that, at some point, the SNP Government will accept responsibility for its own powers and its decisions over the past 15 years, including what we heard today about people who have died in hospital because of this Government’s inadequate performance over the past 15 years—

Will the member give way?

I am sorry, I do not have time.

As the convener of the committee—

Willie Rennie

No. I am sorry: I am not taking an intervention.

From my discussions with the police and GPs, I think that there is very little evidence that the action on additional mental health workers in various places has been delivered.

To compound the problems in primary care, we have heard about the cuts, including the cut of £5 million to the sustainability support package, just when primary care is absolutely on its knees, and the cutting of £50 million that was intended to support the development of health board teams within GP practices, including pharmacists, nurses, physiotherapists and mental health specialists—

Gillian Martin

On a point of order, Presiding Officer.

Speaking as the convener of the committee that produced the report, I say that it is very frustrating when members come to a committee debate for which we have secured time but then do not speak to the motion or the report. I seek your advice as to whether they should.

The Deputy Presiding Officer

I thank Ms Martin for her point of order. The debate is focused on the “Alternative pathways to primary care” report, but it is quite a wide subject area and it is not for the chair to police, in effect, members on the extent to which their contributions have relevance to the broad subject at hand.

However, I am sure that Mr Rennie has heard the concern from the health committee convener and perhaps will wish to address specifically some of the issues in the committee’s report, which is the subject of the debate today.

Willie Rennie

I understand why SNP members do not want to talk about this stuff, because their failure over the past 15 years has been lamentable. It has been a disgrace and—of course—it has had a direct impact on delivery of alternative pathways to primary care. If the core service is not working properly, of course it will not be possible to change the service in the way that the committee quite rightly identifies as being necessary.

This is something that I have passionately believed in for a long time. I have done a lot of work on social prescribing and on making sure that we have mental health professionals alongside GPs in general practices. However, the context is deeply damaging. I understand that the Government and its SNP back benchers do not want to talk about it, but I certainly will, because I have a responsibility to make sure that people understand the failings of the Government.

In saying that, I will give the health secretary a bit of credit. I note that he responded positively to the calls from the BMA for pension contributions with a new recycled employer contribution—REC—scheme to make sure that staff are not deterred from working extra hours, because they were, in effect, paying for the privilege of working for the NHS. I am thankful that the cabinet secretary has agreed to that change, which means that we will be able to free up extra capacity for doctors to help the NHS. That is a positive change.

I have other positive suggestions that the cabinet secretary could also adopt. Resolution of the pay dispute with nurses would be good, as would retaining and recruiting the promised 800 GPs by 2027. He could sort out social care problems, which are so fundamental to the operation of our national care service, deliver the mental health strategy and the 800 additional workers that have been promised. He could lead a programme to help to inform patients about how to access primary care with alternative pathways, in order to make sure that that system works, too. He could improve easy access to, and knowledge and provision of, alternative services, including social prescribing.

I hope that the cabinet secretary will do all those things. I support the committee’s recommendations on self referral, ALISS, the role of the receptionist, the single patient record and digital improvements. I am enthusiastic about those things and am an enthusiastic advocate for those things. Health professionals are, too, but they have very little time to breathe at the present time, which is why all those issues need to be resolved.

I will conclude on a letter that I received from the Auchtermuchty health centre, in my constituency. The letter talks of the system being fragile, and of there being bigger patient lists but fewer staff, and it talks about astonishment at cuts to funds. Finally, the letter says:

“In future, when your constituents complain to you about the lack of GP appointments and services at Auchtermuchty Health Centre, we hope you will ... be honest with them about the limitations of general practice in Scotland and who is responsible for the policy decisions which have led to, and exacerbated, the crisis....”

I hope that I have done that today.


Paul McLennan (East Lothian) (SNP)

I thank Gillian Martin and her committee colleagues for producing the report for debate and I thank the clerks for their help.

In the time that I have today, I want to focus on the role of social prescribing. I have met the Minister for Public Health, Women’s Health and Sport, Maree Todd, about the issue on a number of occasions, as well as hosting a parliamentary reception with the Scottish Social Prescribing Network, which was attended by many organisations from the sector. I thank the minister for the meeting.

As part of the inquiry, the committee was interested in understanding the levels of awareness of social prescribing among patients and health practitioners, and the extent to which effective use is currently being made of social prescribing. Social prescribing is described as a

“means of enabling ... health ... professionals to refer people to a range of local, non-clinical services.”

In its national clinical strategy for Scotland in 2016, the Scottish Government noted that multiple long-term health conditions can result in complex needs, many of which would be best addressed by social rather than medical interventions. To deliver the vision that

“people are able to live more years in good health, and that we reduce the inequalities in healthy life expectancy”

the Scottish Government argues that

“our efforts need to shift towards even greater prevention and early intervention and to local, community-based support across Scotland.”

In 2019, the Health and Sport Committee published its inquiry report, “Social Prescribing: physical activity is an investment, not a cost”. The report explored opportunities and challenges for social prescribing in Scotland. It concluded that social prescribing has clear benefits for the Scottish population and health services. Social prescribing and primary prevention approaches can help to prevent long-term conditions and dependence on pharmaceutical prescriptions. They also have the potential to ease the pressure on existing health and social care services, as well as to reduce waiting times, unplanned admissions to hospital and delayed discharges. The report also noted that there are costs involved, but said that they should be considered to be an investment.

So, what is the potential for social prescribing? Many of the witnesses contributing to this inquiry—

Will the member take an intervention?



I think that Mr Hoy’s card is not in.

Craig Hoy

Does Paul McLennan recognise that, in many instances, social prescribing will focus on sport and leisure, and does he share my concern about the real-terms cuts to council budgets over the past decade, which have impeded councils’ ability to deliver the services that can be used in the context of social prescribing?

Paul McLennan

Yes. Social prescribing is delivered in many ways. I was involved professionally in football for 15 or 20 years and in other aspects of sport. Social prescribing involves not only councils but the third sector. I will come to that a little later.

Many of the witnesses who contributed to the inquiry identified significant potential for social prescribing to patient—in particular, for those who present with problems that are rooted in non-medical issues. Clients experienced decreased social isolation, improved or new housing, the addressing of financial and benefits issues, and increased confidence, awareness, and empowerment. By using local resources, people can become more connected to their community, which increases their sense of belonging.

For GPs, there was a reduction in patient contact with medical services, provision of more options for patients, awareness raising of non-clinical services and increased GP productivity.

In further evidence, Clare Cook from SPRING Social Prescribing and the Scottish Social Prescribing Network argued there should not be a one-size-fits-all approach to social prescribing; programmes must be responsive to local needs.

We have also heard from Alison Leitch, from the Edinburgh community link worker programme, the argument that we need a clear overall lead on social prescribing and that efforts should be made to promote that.

The committee heard evidence that mapping work that is currently being undertaken by the Scottish Social Prescribing Network and Scottish community link worker networks would provide a clearer overview of social prescribing provision across the country. Current mapping shows that most local authority areas have existing social prescribing programmes.

The Cabinet Secretary for Health and Social Care mentioned that he is

“a real believer in the ability of social prescribing to have a positive impact on people”—[Official Report, Health, Social Care and Sport Committee, 29 March 2022; c 17.]—

and expressed the hope that, the more people access social prescribing, the more they will see its value and promote its benefit to others.

What are the barriers to greater uptake? Evidence to the inquiry suggests that at least some of the barriers to greater use of social prescribing remain. The committee heard social prescribing being described as

“the biggest cultural shift in healthcare and medicine that we have had”—[Official Report, Health, Social Care and Sport Committee, 22 March 2022; c 12.]

At the same time, it was acknowledged that the services are not universally available throughout the country, and that that is a barrier to promoting them at the national level. The committee also noted that there is no national lead on social prescribing, given that responsibility for it is shared between two Scottish Government ministerial portfolios. The committee commends the work that is currently being undertaken by social prescribing networks to map availability of social prescribing pathways across the country.

So what is next for social prescribing? The potential for social prescribing is endless, but it must be embedded fully in health and social care in order to achieve that potential. We must have robust evaluation processes to measure the impact that it has on individual lives and on communities. We need to work in partnership with the third sector, which provides most of the community services, because social prescribing can be only as good as the services that are available for people to be referred to.

We need primary care and the third sector to work more closely together to meet the challenges that society faces. We need to work with medical students to embed social prescribing in the medical degree, so that the GPs of the future can see, early on, that a toolbox of multidisciplinary professions is available to them in order to achieve the best outcomes for patients.

Recently, the Welsh Government carried out an ambitious consultation on a framework for social prescribing. England and Northern Ireland already have frameworks in place.

The social prescribing movement in Scotland is being recognised as part of a global social prescribing alliance, through the existing networks. However, it is important that we have an overarching structure that is designed for Scotland, by Scotland, and for the people of Scotland. Ownership is essential to ensuring that the momentum is built on.


Sue Webber (Lothian) (Con)

I was a member of the Health, Social Care and Sport committee when the inquiry started. I acknowledge and thank all those who gave evidence, and I thank my fellow committee members for what was a very eye-opening and informative time in the formal and informal sessions. I found most of the informal sessions to be even more relevant and revealing. I thank everyone for making them so impactful.

As the British Medical Association has said, primary care is the backbone of the NHS. However, it is at breaking point through increasing demands and limited capacity. The expectations that are being placed on GPs and their practices are causing burnout and demoralisation and, ultimately, are forcing doctors to leave the profession. It is therefore very important that we had the inquiry into alternative pathways to primary care—which after all, is for patients; it is a pathway to accessing diagnosis and/or treatment.

Pressures that doctors were previously used to dealing with in winter are now affecting them all year round. As Dr Gulhane said earlier, staff feel like they are working in a perpetual winter, and that has been the case for the past 18 months. The SNP Government is not doing enough to provide alternative pathways right now for the primary care workforce. That makes the report that we are debating even more timely and relevant, and it is why all of its recommendations must be implemented.

One of my constituents wrote to me about his struggles to get an appointment to get a key diagnosis. He got to see his GP, but what came after was a path of confusion and challenging timelines for him. He was initially referred to the Royal infirmary of Edinburgh by his GP, but received a letter saying that he had been triaged by a professor and categorised as “general”. When he inquired what that meant, he found out that it might mean a six-month wait to see a cardiologist. Forgive me for maybe being a bit too controversial, but I am concerned that some pathways are being used as a stalling tactic to prevent people from accessing acute care.

Understandably, my constituent was concerned, so he sought an appointment at the Spire hospital and saw a cardiologist within a week, but that came with a high cost. After an extensive echocardiogram and an electrocardiogram, he was diagnosed with a stenosed heart valve and heart failure, which can be very serious. Thankfully, after an adjustment to his medication, he is feeling a lot better, and the cardiologist has agreed to see him again at his NHS clinic at St John’s hospital at the beginning of March.

My constituent is in a rare cohort, because he understands self-referrals and how the processes in NHS acute and primary care work. He is also very aware of the challenges that all healthcare professionals are facing, but he knew that he needed the diagnosis. People should not have to seek that route in order to access healthcare and get the treatments and diagnoses that are needed to save their lives. Luckily, my constituent was able to do that, but many people are not. The consequences are that Scotland’s healthcare is turning into an unfair two-tier system in which care depends on what people can afford. That is not the alternative pathway that we are here to discuss today, but it is the reality.

The NHS staffing crisis is all around us, and one branch of the service in which we could do more—in order to alleviate pressure on hospitals—is primary care, whose practitioners are the backbone of and gateway to the system, as the minister stated in her remarks. That branch of the service is in as much crisis as the care system, and the list of practitioners, including GPs, allied health professionals, nurses and podiatrists is extremely extensive.

Again, the number of qualified medical staff cannot keep pace with growing demand from an ageing population and the expansion of housing estates. At 3,600 full-time equivalents, the number of GPs is virtually unchanged, while the population has risen to 5.47 million and is expected to grow by another 10,000 in the next six years.

Housing developers happily commit to building new GP surgeries in their sprawling new estates, but with no idea of where qualified medics will be found. Why should they have any idea? As 5,000 homes go up around Winchburgh, it is not the responsibility of Cala Homes or Taylor Wimpey to source doctors and nurses.

Scotland’s GP workforce shrank in the six years leading up to the pandemic. In 2017, the SNP Government pledged to increase by 800 the number of GPs in Scotland by 2027, but it is not on track to achieve that. We want to see an increase in training places, in order to deliver the 800 more GPs by 2027 that were promised and to ensure that all GPs are supported by a wider—and invaluable—multidisciplinary team. That would enable GPs to offer longer appointments to people who need them.

We would train more independent prescribers to enable pharmacists to treat a wider range of common conditions and we want social prescribing to be embedded in primary care. That includes rolling out community link workers and making links to advice services more widely available.

Alternative pathways to primary care provide a vital way to alleviate the burden on overstretched GPs and other healthcare professionals. The pandemic might not have been the genesis of all those issues, but its shock waves have exacerbated them to the state of urgency and crisis that we face now. More work is needed in order to roll out alternative pathways, ease the pressure on GPs and take cognisance of all the report’s recommendations. They are all welcomed and we support them today.


Evelyn Tweed (Stirling) (SNP)

I was very pleased to be involved in the alternative pathways to primary care inquiry, and I thank everyone who engaged with the committee on that work.

Although recent research by the Nuffield Trust shows that Scotland has a record number of GPs and the highest number per head of population in the UK—76 GPs per 100,000 people compared with a UK average of 60—there is no doubt that they are under pressure.

Alternative pathways to primary care are freeing up resources. For example, through the pharmacy first service, local pharmacies can now treat minor conditions that would previously have required a GP appointment. By autumn 2022, pharmacy teams had already carried out more than 3 million consultations for minor illnesses while referring less than 5 per cent of cases to other healthcare services.

I will use my local health board to demonstrate the benefits of alternative pathways. The population is growing, and the number of residents aged over 65 is increasing even more rapidly. However, NHS Forth Valley has already been able to extend GP appointments from 10 to 15 minutes through, for example, piloting the use of physiotherapists and mental health nurses in local GP practices.

Children are being vaccinated in the community by dedicated immunisation teams, and there is an innovative website that supports social prescribing for both patients and healthcare staff, which provides details of a range of alternative resources.

As part of the 2018 GP contract, more than 3,000 whole-time-equivalent multidisciplinary team members have been recruited, including pharmacists, mental health workers and physios. That has great potential to ease the pressure on GPs and to promote greater use of alternative pathways through the creation of MDTs that carry out primary care functions in a patient-centred manner.

Will the member take an intervention?

Evelyn Tweed

I will not at the moment, but maybe soon.

However, key elements of the contract have been delayed due to the Covid-19 pandemic.

As the convener noted, through a survey, the committee saw evidence from the public that highlighted a lack of awareness of services as a problem. For a long time, GP services have been the clear first port of call for healthcare, and the survey revealed a high level of awareness of opportunities to self-refer for some services, such as dentistry and optometry. However, awareness of the opportunities of self-referral for other services, such as audiology and mental health, was much lower.

It is clear that many people value GP services highly and feel dismissed when sent on an alternative pathway. The “Right care, right place” campaign, which included radio and television broadcasts as well as a booklet that was sent to all households across Scotland in January 2021, has not fully addressed public understanding or acceptance of, for example, the enhanced role of GP receptionists and options for self-referral. Perhaps a similar campaign needs to be re-run while the lessons that have been highlighted are learned in order to support that significant culture shift. I am encouraged by the cabinet secretary’s response and openness to continued dialogue with the committee on that matter.

I am pleased that the Scottish Government is also exploring the potential for standardising training for administration staff who work in primary care, in order to improve relationships between admin staff and patients. It is also good to see that, after such a challenging few years, £8 million is being invested by the Scottish Government to support the physical, mental and emotional needs of the workforce.

Thanks to the reckless and self-serving decisions of the Westminster Conservative Government, the Scottish health budget—[Interruption.] I hear groans from across the chamber, but the Scottish health budget is now worth around £650 million less than it was in December 2021. In addition, austerity has had a terrible effect on—and has shortened—the lives of Scottish people. Our committee knows that, because we took evidence on it.

The Scottish Government’s promotion of alternative pathways to primary care cannot make up for Westminster’s incompetence and austerity, but it can—

On a point of order, Presiding Officer.

Ms Tweed, would you please take your seat? Tess White has a point of order.

I did not know that that was in the committee report. Thank you.

Ms White, I am not clear what that—

I am just questioning the relevance.

The relevance of what?

The relevance of Westminster. The United Kingdom Government has no bearing on the committee report. Thank you.

The Deputy Presiding Officer

Thank you for your point of order, Ms White. As I said to Gillian Martin, in response to her point of order, I, as the chair, am not here to police the contributions of members as long as they bear broad-brush relevance to the subject at hand. That is what I said in response to Ms Martin’s concern about the previous speaker’s contribution, and that is the answer that I give you, Ms White.

Ms Tweed, please continue.

Evelyn Tweed

Thank you, Presiding Officer. I will finish on that last point.

The Scottish Government’s promotion of alternative pathways to primary care cannot make up for Westminster’s incompetence and austerity, but it can help to better distribute resources and capacity in healthcare to ensure that everyone gets the care that they need from the most appropriate practitioner.


Sarah Boyack (Lothian) (Lab)

I thank the committee for its report, because it is vital work. The speeches by Carol Mochan and Willie Rennie were powerful in highlighting the pressures that primary care faces today. In my contribution, I want to make the links between the ambition of identifying alternative pathways to care and delivering to communities across Scotland. I also want to take the opportunity to talk about the evidence that we have had in the Constitution, Europe, External Affairs and Culture Committee and the work that I have been doing with the culture sector, in which social prescribing has come up in discussions time and again as something that is considered to be crucial for supporting people’s health and wellbeing.

On one level, it is inspiring to see the work in our communities. On another level, it is incredibly frustrating that it is now over a decade since the Christie commission’s recommendations on investing in prevention were made and we have not seen fast enough progress. So, I very much support the committee’s recommendation to map availability across Scotland. I think that that is important.

When we questioned the Cabinet Secretary for Health and Sport at our Constitution, Europe, External Affairs and Culture Committee evidence session in March, his timetable for action in social prescribing was to ensure that,

“by 2026, every general practitioner practice will have access to a mental health and wellbeing service,”

with the aim of helping

“to grow community mental health resilience and direct social prescribing at a grassroots level”.—[Official Report, Constitution, Europe, External Affairs and Culture Committee, 17 March 2022; c 20-21.]

Although I welcome the ambition, it is years late. My frustration is that, although the cultural sector in Scotland is already providing fantastic wellbeing activities that are targeted to support people and help their wellbeing—even as the sector faces a perfect storm—we do not have a connecting delivery strategy to make the links between health and culture that we really need now.

We know from research that social prescribing works; we just need to get on with mainstreaming it and making it available to those who need it. Therefore, I very much welcome the health committee’s recommendations that we are debating today. In particular, I welcome the acknowledgment that cost is a key barrier for people on low incomes.

A University of Glasgow report from 2020 examined the impact of the link worker programme, which was a social prescribing initiative for areas of high deprivation in Glasgow that was designed to address health inequalities. Interviews were conducted with community organisation representatives and community links practitioners. The empirical evidence of the positive impact in areas of deprivation is really important to highlight. Social prescribing allowed people to be engaged who would otherwise not have benefited from services outside formal primary healthcare. A powerful quote from the research was that the challenge is in

“Reaching the people who are hardest to reach. The people that don’t realise that—although they might be aware of us, they don’t realise that we could actually help them.”

The study also reported an increase in the need for services at the same time as funding cuts have left organisations with massively reduced resource.

“Projectism” is what we call it in the CEEAC Committee, from the evidence that we have had. It is how cultural organisations have described the challenge that they face. With rising demand, organisations are focused on getting through crisis after crisis, but they are not able to do the long-term work on building relationships with the people who need it. From other research that was published last year, we know the challenge that social prescribing co-ordinators face following the shift towards delivering services digitally, so there is an awful lot that needs to be addressed now.

I highlight the point that social prescribing links our health and cultural sectors. It is crucial for post-Covid recovery to support people through the pressures and anxiety that are now coming through the cost of living crisis. It would be a practical way to promote health and wellbeing now and to avoid people getting further and further into the health system when there is a way to enable them to be supported now.

Practical work is being done now. Over the past 12 months, I have been able to hear from various organisations about the benefits that they are delivering with joined-up approaches. I had the pleasure of sponsoring the exhibition and reception to celebrate the incredible work that Art in Healthcare does to improve health and wellbeing by using visual art in healthcare settings, humanising our medical environments to support staff and patients. The University of Edinburgh’s prescribe culture pilot is aimed at increasing access, and the brochure for its take 30 together virtual programme is available and free to download. At a recent meeting of the cross-party group on culture and communities, we heard from people involved in the archive services at the University of Dundee about the huge benefits that social prescribing had for their mental health. Then there is the excellent work of the Tayside Healthcare Arts Trust.

I also highlight the fantastic work of National Museums Scotland on its museum socials. For seven years, as part of its learning programme, its community engagement team has hosted museum socials for people who live with dementia. They are an informal learning experience and give participants a range of opportunities to engage with national collections and wider social activities. The socials also support their family members.

The report that National Museums Scotland has done on health and wellbeing is superb. It is definitely well worth reading. We also have National Galleries of Scotland’s work on access to mindfulness, dementia-friendly access and a commitment to autism and sensory-friendly access.

That work needs continuing support, and we need similar projects right across the country so that every local community can access them. Although it is not just a question of funding, multiyear and predictable funding is essential. That is the constant message that we get from the cultural sector. After that, making links with the health sector is essential. I strongly support the committee’s call for action to support voluntary sector providers to address long-term financial viability. We are in a perfect storm, and the Scottish Government needs to address the issue now.

Physical activity prescribing is becoming more common and is delivering benefits for people and our health service, but we need culture prescribing to become legitimate, with clear political leadership from ministers, as the committee recommends. The committee’s suggestion of work to deliver a targeted communication strategy to raise awareness of the positive impact of social prescribing is really important. I hope that ministers will take that up.


Stephanie Callaghan (Uddingston and Bellshill) (SNP)

I thank primary care staff and everyone who provided evidence to our committee, including patients who told us their personal stories. I also thank the other members of the committee, especially our convener, Gillian Martin.

As other members have said, primary care is the backbone of our health service. One of the points that came up was the question: what is primary care? When asked, most people will say that it is about their GP but, as we have heard, it is about much more than that. It includes community nurses, physiotherapists, occupational therapists, dentists, those who provide end-of-life care, health visitors and many others. That is not to forget the invisible support staff who back them all up.

Primary care is the first point of contact with healthcare for most people, and strong primary care is central to an effective and sustainable health service. In general practice, our GPs are busier than they have ever been. GPs and their teams are striving to meet spiralling patient demand and to establish key primary care networks. In Lanarkshire, there has been an increase of between 40 per cent and 50 per cent in demand for patient appointments.

The challenges of Brexit, the pandemic and 12 years of austerity have all hit really hard, and the current level of inflation is yet another threat that we face.

The need to reform general practice and deliver alternative pathways has never been as pressing as it is today. However, it is a challenging area for reform, both in Scotland and internationally. Our access to primary care is deeply affected by many factors, including resources, staffing and planning. A lot goes on in primary care: as we heard repeatedly in the committee, services are working really hard to adapt at a time when resources are already stretched to the limit, which is compounding the barriers to sustainable and effective change. However, that does not mean that we need to slow down; rather, it means that we need to work even harder to ensure that we meet those challenges head on.

We also need to be mindful that the public are being asked to adapt, too, at a time when they have never been more anxious or confused about access to care. The public might think that the process has started just because of Covid, so we need to get the recognition out there that it started before then. It is not just a response to Covid; it is the right thing to do.

Transformation is needed, and the success of our NHS will depend, to some extent, on our ability to increase access to, and awareness of, alternative pathways to primary care. Those pathways include receiving advice or treatment from allied health professionals, using social prescribing initiatives and accessing websites or using telephone services. People can do those things instead of going directly to their GP every time.

The term “alternative pathways” might be slightly confusing, because we really mean effective pathways to receiving better care. We might need to communicate that a bit more coherently.

During the inquiry, the majority of people did not quite understand why we were reforming general practice. Again, we really need to talk about that message. A general practice is a community asset that should act as the glue that connects all other healthcare services and professionals, rather than being the single focal point with patients dependant on a particular GP.

There is so much more in the report, and we have heard so much about it already today, but I want to touch on three bits of it: community social prescribing, digital opportunities and recruitment challenges. In some cases, there was an increase in uptake of social prescribing during the pandemic. The comments that we got from patients were really positive. They noted

“quicker and better health outcomes”.

However, the evidence suggests that some people were

“reverting back to their GP”,

so we need to take on board that it will take time for behaviours to change.

In my constituency in Lanarkshire, the community link workers programme offers full coverage across all practices. This year, more than half of Lanarkshire’s GP services referred into the GP community link workers programme, with just under 300 referrals. The most common reasons related to mental health issues, but we know that social prescribing can be effective for physical health and fitness, too—it can have a huge impact in that regard. I would welcome an update on any plans that the Scottish Government has to develop social prescribing further in order to build on that success, particularly around a national lead to improve delivery.

On digital opportunities, our report highlights that digital progress will be key to transforming healthcare for patients and health professionals. I read the recent Scottish Government report, “Care in the Digital Age”, which sets out the delivery plan as we move through the rest of this year to 2023.

We want to see easy-to-use patient apps that provide easy access to appointments and test results. That is a huge thing. A single electronic patient record is another huge thing. If health and care professionals across the NHS and social care could access such a record, that would make a huge difference not just to them but to their patients.

The reality on the ground is that a lot of time and money is being invested, but, just now, a lot of that is going into information technology systems on strengthening cybersecurity and training up staff. Although I recognise the complexities and level of background work in that area, I hope that the cabinet secretary will offer a bit of reassurance that developing digital apps and records will be a priority for the future. I know that it is challenging, but it is vitally important.

I will briefly mention recruitment, which is a really challenging area, as other members have said. However, to touch on some positives, I welcome the Scottish Government’s winter plan, which commits to recruiting 1,000 additional staff, including 750 nurses and 250 support staff, over the winter season.

Please conclude, Ms Callaghan.

Alternative pathways to primary care can help to ease some of the pressures on GPs and on other areas of the NHS. There is still a lot of work to do, and I call on the cabinet secretary—

Ms Callaghan, you must conclude.

—to focus on building those pathways and to keep the committee and the Parliament updated.


Gillian Mackay (Central Scotland) (Green)

As many other members have done, I thank the clerks, my colleagues on the committee and the people who gave formal, informal and written evidence to the committee.

The way in which services are delivered has changed significantly over the past few years, with both primary care reform and the pandemic having an impact.

In written evidence, the Royal College of Physicians and Surgeons of Glasgow indicated that the understanding of alternative pathways to healthcare is poor among patients. It noted that, although

“patients may be aware generally about alternative pathways, it may be limited about specific pathways. It may also be guided by personal experience of both practitioners and patients and what is available locally.”

The Royal Pharmaceutical Society also highlighted limited patient awareness of alternative pathways and multidisciplinary teams. A greater emphasis must be put on advertising and normalising the use of multidisciplinary teams and alternative pathways. There is a particularly acute need for that ahead of winter to ensure that everyone gets the help that they need.

We must ensure that advertisement of alternative pathways reaches everyone. Many people do not use social media, and some will not see adverts on television because they use only streaming services, so we must ensure that the ways in which we communicate are accessible and clear and show the multiple pathways that people can take, to truly ensure that there is a no-wrong-door approach.

Glasgow city HSCP argued for action to encourage a change in behaviour from people automatically seeking help from GPs in the first instance. However, it acknowledged that such changes can take significant amounts of time to become embedded in practice.

Evidence was given to the committee of a good understanding of how and when to self-refer to dentists, optometrists and pharmacists. However, there is a lack of awareness of the full range of services that those practitioners offer.

Patients are not currently afforded the same level of access to audiology services, and the National Community Hearing Association Scotland outlined current obstacles to self-referral for patients with non-urgent ear and hearing problems. It said:

“The current model of NHS care means each year patients are forced to see their GP for non-medical ear and hearing problems, which can be better managed in primary care audiology settings.”

It also said:

“in some cases, the GP in a pathway adds costs without adding value, resulting in an overall loss of scarce NHS resources. This is particularly true for most ear and hearing problems where primary care audiology is, in the same way as optometrists for eye care problems, much better suited to managing needs, freeing up GP capacity to address medical issues.”

Many people will experience hearing loss over the course of their life, and we must ensure that there is parity of access to services, no matter the sensory issue that people are dealing with. As someone with a hearing impairment, I might be slightly biased on that, but I note that I can often get easier access to eye tests than I can to primary care support for changes to my hearing. People often do not need support from the hospital audiology team, and being able to refer straight to primary care audiology would save time for GPs and secondary care teams.

I recognise the issue of potential duplication of effort, which was raised by the Royal College of General Practitioners in its evidence. There is always potential for patients to be signposted or self-refer to a service that does not wholly fit with the issues that they are experiencing, and I am sure that many GPs would say that, sometimes, the issue that a patient comes in with is not exactly what they think it is. However, for patients, there is an issue of ownership of their own care. In evidence, the suggestion was made of a system to request fast-track follow-up by a GP for patients who need it. That might offer a sensible solution but, if put in place, it would need close monitoring and evaluation involving patients and clinicians.

There is a lot to cover in the committee’s report, and I do not think that I can do it justice in the time that I have remaining. I will use the remainder of my time to focus on one of my favourite topics: data.

One of the barriers to allowing smooth sharing of data between multidisciplinary teams is the lack of ability to share data easily. As many members have said, many of our witnesses cited a single electronic patient record as being transformational in allowing seamless access between services. We also heard from patients that such a record would prevent them from having to retell their story multiple times. It is exhausting, sometimes really upsetting and, for some people, retraumatising—especially for those who need to access mental health support or on-going support because of an impairment—to have to retell their story and to explain how they came to experience their symptoms and what led them to access the service. A single patient record is essential in ensuring that we do not retraumatise people.

There are also very practical reasons for single patient records, such as the fact that they allow people to take all their information with them when they move, rather than having to request that a copy of their records be sent to their new GP. Thousands of people move away from their current GP practice area every week and, in 2022, it should be simpler for them to move their data. I was pleased to hear the cabinet secretary indicate to the committee that that is a priority, and I would welcome any update that he can provide on that.

I again thank everyone who gave evidence to the committee and the people who continue to support us in our on-going work.


Craig Hoy (South Scotland) (Con)

The Health, Social Care and Sport Committee’s report on alternative pathways to primary care highlights a crisis in our primary care sector and it makes a number of recommendations that I hope that the Scottish Government will act on. I thank the committee for its report, which serves only to highlight the challenges that face our NHS and the staff who work in it under the current SNP Government.

The problems are long running and they are well known, including to Scottish ministers. Staff are overstretched and undervalued. Routine primary care appointments are being cancelled up and down the country, and many patients are struggling to access primary care. Self-referral pathways are not clear and they are not advertised well enough; the primary care sector is unable to keep up with rising demand as a result of poor workforce planning by the SNP Government; and, now, for the first time, nurses—the beating heart of our NHS—are set to strike.

In my region, we can see at first hand the problems. GP patients face challenges in booking appointments in areas such as Gullane, Port Seton and North Berwick. Pharmacies in Haddington and Galashiels have faced repeated unscheduled closures. Boots pharmacy in Haddington frequently has a closed sign pinned to its door, which means that it is shut to patients who need prescriptions or access to the services that are delivered through pharmacies. Those are important pathways and they should remain open.

The British Medical Association has warned that primary care in Scotland faces a “critical workforce supply problem” and that the Scottish Government needs to have a credible plan. Just last month, I warned that a rise in unexpected pharmacy closures as a result of the Scottish pharmacy contract is an issue of concern. The pharmacy contract means that the Scottish Government continues to pay for pharmacies to stay open even when they are closed without any reason. The Pharmacists Defence Association has warned that some large pharmaceutical chains, such as Boots and Lloyds, may be exploiting that loophole—without facing any consequences—to maximise profits at the expense of people who need pharmacy care. As the report makes clear, the root of that problem is, yet again, poor workforce planning by the SNP Government.

The Government also needs to put in place an adequate strategy to recruit and retain GPs. It is vital that the Government takes action on that. In 2019, Audit Scotland warned that, by 2027, the Scottish Government’s target of recruiting a net total of an additional 800 GPs would not be met. The number of GPs who are coming through the front door is being offset by the number who are leaving. In a report this year, Audit Scotland continued to warn that the Government should give more priority to the recruitment and retention of GPs, and, indeed, to that of staff throughout the health service.

There is also the issue of mental health. Signposting in the workplace continues to be poor. Every year, up to 650 people in the UK take their own lives as a result of work-related mental health issues. A survey by See Me Scotland this year found that 77 per cent of respondents with poor mental health said that they had experienced unfair treatment in the workplace because of their mental health.

Support in Mind Scotland’s director, Jim Hume, has said:

“Training staff in mental health can help to break down stigma and discrimination, build awareness, develop skills and enhance confidence ... Findings from the project have demonstrated that 91% of people who participated say they have an increased awareness and understanding of mental health following the training; and 87% of participants feel more confident to talk about mental health with their staff/and or colleagues.”

He added that the

“evidence highlights how mental health training is a valuable resource to build resilience and reduce stigma in the workplace by increasing people’s knowledge of mental health, breaking stereotypes and building people’s confidence to be a ‘first responder’.”

The committee’s report rightly stresses the important role that community link workers and primary care receptionists play in signposting patients, but it is vital that services are there once that signposting takes place. There is concern about Government cuts, particularly in relation to the mental health budget. During the previous session of Parliament, the SNP broke its manifesto pledge to recruit 250 more community link workers to GP practices. Will the Government ensure that filling those vacancies is a priority?

Sadly, that is part of a pattern of empty promises and shallow words by the health secretary and his Government when it comes to Scotland’s health system and, most important, to the hugely valuable staff who work in it. We need action to support primary care and invest in health care up and down the country. When we offer alternative pathways through, for example, sport and leisure, as I said to Mr McLennan, we must ensure that we properly fund community organisations and councils to deliver those, rather than get the real-terms cuts that we have seen in good times and during the current turbulence.

Local health and social care services continue to be decimated by this SNP Government. In South Scotland last year, we saw the closure of North Berwick’s Edington cottage hospital. GPs worked very closely with that hospital to ensure that local need was met. The closure took place without any consultation with local residents or primary healthcare professionals. We now see such behaviour writ large in the SNP’s plan to plough ahead with a national care service, against the advice of third-sector organisations and social care experts. Any problems in social care will only add to the pressures that we already see in our stretched primary care sector.

This Government is ignoring the crisis in primary care and the wider crisis in our NHS. Yet again, its priorities, and those of Humza Yousaf, lie elsewhere. He has taken his eye off the ball and it is time that he was removed from the pitch.

Emma Harper is the final speaker in the open debate.


Emma Harper (South Scotland) (SNP)

As a member of the committee, I welcome the opportunity to highlight and focus on our report. It has been interesting to hear others’ contributions.

The report highlights that primary health is vital in ensuring people are seen by the most relevant professional for their needs and is crucial in relieving pressure on secondary care, particularly when our NHS is under the greatest pressure that it has experienced in its 74-year lifetime as we emerge and recover from the pandemic.

We looked at a wide variety of areas in our report on alternative pathways to primary care. I thank the witnesses, clerks and my colleagues for their input. We heard about community link workers; ALISS, which is an online local digital system for signposting and supporting people; the role of digital health and care; single electronic patient records; third sector involvement; and a lot more besides. I will focus on social prescribing and recruitment.

Social prescribing was not a widely used term during the previous session of Parliament, but more and more people now understand what that is and what its benefits are. In our report, the committee welcomed the increased uptake of social prescribing during the pandemic and the positive lived experience that those who have used it told us about. The evidence that we heard shows that social prescribing is effective in targeting the causes of health inequalities and that it can vastly improve mental health and wellbeing. We have heard others highlight that during the debate.

However, the committee took evidence that patients who used social prescribing during Covid recovery are now reverting to contacting their GP in the first instance, even though on-going use of social prescribing could offer better outcomes.

We heard how cost is a critical barrier to people accessing social prescribing pathways, particularly in areas of multiple deprivation. One point that came up is that there is no single national lead on social prescribing because responsibility for it is shared between two Scottish Government ministerial portfolios. I ask the minister to provide an update on the Government’s work to simplify the national approach to social prescribing and to better align ministerial portfolios so that there can be leadership and accountability on social prescribing in alternative pathways to primary care.

I turn to recruitment. The committee heard evidence to suggest that sustainable long-term workforce planning will be a critical prerequisite for encouraging greater use of alternative pathways to primary care in the future. Evidence that was submitted to us suggests that that must include consideration of how roles and skills requirements are likely to change as a result of advances in technology and the on-going evolution of services and their delivery.

I agree with Alison Keir of the Allied Health Professionals Federation Scotland and others who have indicated that it is really important not to look at workforce planning around team members but to understand it from the point of view of population-health need. We must plan the workforce from that perspective rather than say that we need X physiotherapists, occupational therapists, dieticians and so on.

I welcome the Cabinet Secretary for Health and Social Care’s launch of a new GP recruitment campaign this June, as part of the Scottish Government’s commitment to increase the number of GPs in Scotland by 2027. By highlighting the flexible, supportive and collaborative environment that is available here, the campaign seeks to encourage GPs from the rest of the UK to relocate to Scotland. That campaign is in addition to the Scottish graduate entry to medicine programme—ScotGEM—which allows graduates with healthcare and science degrees to train to be GPs with a particular focus on rural medicine. Dumfries and Galloway is part of the programme, and feedback from that areas ScotGEM lead is extremely positive.

Scotland is struggling to recruit in social care and nursing. A fall in the size of the working-age population and the ending of free movement of people as a result of Brexit have contributed to those challenges. Although the Scottish Government’s steps are welcome, recruitment and retention of the workforce across multidisciplinary teams will be crucial to our success in promoting greater use of alternative pathways to primary care. That will be a particular interest of mine as we scrutinise the National Care Service (Scotland) Bill. The committee’s report recommended that the Scottish Government provide an update on its work to assist health boards in developing an integrated approach to workforce planning and overcoming recruitment challenges.

The report also describes strengthening people’s understanding of the role of medical receptionists, who are critical in signposting folk to get the support that they need. I welcome the Scottish Government’s right care, right place campaign, which aims to increase that understanding. I am sure that lots of work has gone into creating the campaign, but my concern is that it mibbe isnae reaching the public as effectively as it could. Perhaps it needs a relaunch and for its messages to be shared again. I will use my social media accounts to share them and I encourage colleagues to do the same with theirs.

There is loads to read in the report, which was published in June. Securing parliamentary time to debate our committee reports is crucial. I encourage all members to read the report and to share its contents, because it has a lot of worthwhile material in it.

We move to winding-up speeches.


Martin Whitfield (South Scotland) (Lab)

It is a pleasure to close this fascinating committee debate on behalf of Scottish Labour.

I express my deep appreciation for the Health, Social Care and Sport Committee’s work on its report. Some of the statistics in it will be challenging for members to read, but I think that it is the sign of a mature Parliament that we are prepared to go out and find such information and then address it. My huge compliments go to the committee’s support staff and its members both past and present. I echo my colleague Carol Mochan in saying that Scottish Labour supports the findings of the committee’s report.

Before I deal with some of the contributions, which I think have been interesting for a committee debate, I want to pick out two aspects, because of my own interests—and I look to the cabinet secretary for comments, given that the research that I will refer to in a moment has been funded by the Scottish Government.

First, was any attempt made in the committee’s report to capture the primary care experiences of children under 18? After all, their journey to adulthood is often, I am sad to say, shaped by too many journeys to the GP surgery, too many journeys to the dentist and, in the case of my young children, far too frequent visits to accident and emergency.

I commend to Martin Whitfield our other report on access to healthcare for children and young people, which contains a lot more detail on that.

Martin Whitfield

I whole-heartedly accept that invitation.

The other aspect of the statistics that I want to highlight—and I want to point out, in a nerdy way, that I am going to talk about figure 15 on page 25 of a certain Scottish Government survey—is the fact that the experience of 18 to 29-year-olds is different from that of almost any other demographic. That is a concern; for example, with regard to the question,

“Thinking about your work, family and other commitments, how difficult or easy is it being available for appointments during opening hours?”,

the 18 to 29-year-olds were the only group for whom it was far more difficult to attend an appointment during opening hours.

In fact, that point has been highlighted in a number of contributions, to which I will now turn. I think that some very powerful speeches were made this afternoon. Sandesh Gulhane was able to give us the real lived experience of a GP’s day, and his comments certainly echoed what the many GPs to whom I have spoken have told me about the challenges that exist. I also want to highlight—and rightly so—Carol Mochan’s very powerful speech on the same issue.

I want to pause at Willie Rennie’s speech. I hope that he is not concerned about my being detrimental about him, because I, too, think it important to look at the background to the report. We do the report an injustice if we do not recognise the challenges in our health service. Just to echo the latter part of Mr Rennie’s speech, I think that we have, without doubt, the opportunity to find a pathway to a better future, but it will be a very hard journey, and I urge the Government to recognise the challenges, which I hear so often raised in the chamber, to ensure that those working across the whole of our national health service, in primary care and in our communities get the support that is so often promised.

I must apologise to Paul McLennan, as I had to step out of the chamber on to an alternative primary pathway—that of my family—but I will read his speech. That said, I caught the end of it, and I was interested in the point that he made about promoting community prescribing to GPs in training. I do not underestimate the challenge of alternating undergraduate courses, having tried to do the same in teaching, but I think that a recognition of that very valuable service would be an important element of how we might train a better group of professionals.

I must pause at Sarah Boyack’s speech to bring into the discussion the hugely important issue of culture. Culture has played a role in protecting our community’s mental health by giving us art that we hate as well as art that we love, music that is too loud for our parents as well as music that is the best we have ever heard, dancing that annoys the boys, poetry that sometimes annoys the girls—particularly in February with Valentine’s cards—and so on. The role of culture in supporting a human being to be a human being should not be underestimated, and we recognise its crucial value in prescribing it outwith traditional drugs or other treatment. It could be a great missed opportunity, particularly at this time.

Stephanie Callaghan’s incredibly powerful contribution captured one of the biggest discussion points in today’s debate: the challenge of taking this information out to our communities and the need to do so. We have plenty of good examples to draw on. Covid brought back to us the simple pleasure of walking outside or by the sea, but giving people an understanding of what a GP does and what primary care is will be crucial to our making any of this work. In that respect, the member’s call to review how that sort of thing is announced and put out to our communities is crucially important.

In the few seconds that I have left, I want to mention the GPs who contacted me this morning to say that there is a discussion that must be had about the GP contract. They tell me that they are disappointed by the Scottish Government’s “reneging” on the GP contract as a result of the cuts in funding that have been announced. I know that there is a massive pressure on Government budgets because of inflation, but that same inflation is hitting every GP surgery, pharmacist, dental surgery, ophthalmology department and community across Scotland. The people of Scotland understand the challenge that the Scottish Government has, and I hope that the Scottish Government hears the challenge that the people of Scotland are putting to it, about how to make the situation better and move forward.


Tess White (North East Scotland) (Con)

I am pleased to close the debate on behalf of the Scottish Conservatives. We all agree on the importance of the work that the committee has done.

The undeniable reality is that our NHS is severely overstretched, and that is especially the case in primary care. Despite the best efforts of GPs and front-line staff in surgeries across Scotland, primary care is struggling to keep pace with demand and increasingly complex patient needs. Stephanie Callaghan quite rightly talked about the value of the personal stories that the committee heard. Evelyn Tweed said that there is no doubt that primary care is under pressure. That is a massive understatement. The deputy chair of the BMA’s Scottish GP committee put it bluntly, as she rightly should. She said:

“This is a particularly terrible time for general practice.”

There is a wider issue, which is that the whole system is overwhelmed, from GP practices to A and E. We are seeing record waiting times month after month, and things are getting worse, not better. The NHS is on its knees.

Earlier, the committee’s convener highlighted workforce and capacity issues, poor signposting, digital exclusion, limited public awareness of the changes and the fact that people feel that they have been fobbed off. There simply is not the necessary capacity in place, yet public messaging from Humza Yousaf and health boards such as NHS Grampian in my region is directing patients away from emergency departments to non-critical care. As the Royal College of General Practitioners says, that approach means that

“pressure is not relieved, only reallocated.”

The question is how we navigate through this crisis so that patients receive the timely, targeted and high-quality care that they need and so that primary healthcare professionals do not experience burnout. It is here that the Health, Social Care and Sport Committee’s work on alternative pathways to primary care makes an important contribution.

As we have heard during today’s debate, the Scottish Conservatives believe that alternative pathways to primary care provide a vital way to alleviate the burden on overstretched GPs and other healthcare professionals. My colleague Craig Hoy warned again of a rise in unexplained pharmacy closures due to the Scottish pharmacy contract—I stress that pharmacies are a key alternative pathway to primary care. In the first five months of this year alone, staff shortages caused pharmacies to close almost 1,800 times.

Will the member take an intervention?

Tess White

I have a lot to get through, if I may.

Sue Webber raised relevant and revealing inputs to the committee, such as the appalling case of her constituent who was struggling to get an appointment with a cardiologist to diagnose a heart condition and who had to seek private treatment at significant cost.

Maree Todd calls primary care services the front door to the NHS. The Scottish Government feels that it has communicated well with the Scottish public around seeing physios, pharmacists, optometrists and podiatrists. However, as Sandesh Gulhane said, the public, largely, do not know about the changes. That is a huge concern.

Dr Gulhane also tells us that 42 per cent of junior doctors lack access to nutritious food at work, which, obviously, leads to burn-out.

The renegotiated GP contract in 2018 changed the delivery of primary care so that GPs would provide fewer services directly and multidisciplinary team working would be enhanced. However, the committee’s report highlighted concerns that public awareness of those changes is limited. That has certainly been my experience of talking to constituents in the region that I represent. It is heartbreaking.

In his passionate words, Willie Rennie said that we must pray that, at some point, the Government will take some responsibility.

Gillian Martin outlined the need for advertising. I agree with that. Patients are bewildered by signposting to alternative health practitioners when they have simply requested to speak to their GP. They do not understand why their winter vaccinations are being delivered an hour away and their bus has not come again, as they usually just nip down the road to their local surgery. They are getting frustrated with practice receptionists, who are often the faces of systemic change that has been poorly managed and poorly communicated to the public by the SNP Government.

The most recent health and care experience survey should be a wake-up call to the Scottish Government. Only 67 per cent of patients said that they were positive about the overall level of care provided by their GP. That is down by 12 per cent on the previous year and is the lowest level since the survey began.

Primary care needs to be reformed, but that process needs to be clearly articulated to the public. It needs to be patient centred, not just system focused.

As my colleague Carol Mochan has pointed out, the Scottish Government has failed to communicate its vision. She said that the narrative of the SNP Government “is simply not true”. Services are overwhelmed.

We know, of course, that Scotland is in the middle of a primary care workforce crisis. The British Medical Association has warned about that. The minister’s front door to the NHS is off its hinges, and a gale is blowing. The BMA is clear. It has said:

“without additional health professionals across a range of areas it will be near impossible for primary care to offer the range of services communities need or expect.”

The crisis is a crisis of the SNP’s making over many years. The health secretary simply is not doing enough to provide the resources that alternative pathways to primary care desperately need to ease the pressure on GPs.

As winter approaches, the crisis cannot become a catastrophe under the SNP Government. I thank Martin Whitfield, who highlighted the importance of people—people in the NHS who are watching us today and people who are receiving life-saving services. Patient safety and the wellbeing of staff are at stake—and so are people’s lives.


The Cabinet Secretary for Health and Social Care (Humza Yousaf)

The debate has generally been quite a good one, and lots of important themes have been highlighted.

I thank all the members of the Health, Social Care and Sport Committee for an excellent report. I also thank all those who gave evidence and, of course, the committee clerks, who, as we know, do the real hard work. I am just kidding—members do fantastic work, of course, but we know that the clerks are instrumental in producing such excellent and high-quality reports.

I will reflect on some of the common themes that members across the chamber have mentioned.

Almost every member has spoken about the really challenging context of primary care. Dr Gulhane gave a personal example of a day in the life of a GP. It will not surprise him that I have met many a GP in that role who has described similar workload challenges. Last week, I met Dr Andrew Buist of the BMA’s Scottish general practitioners committee, who described again the really challenging pressures. Members will not have any denial from me, as the health secretary, of the scale of the challenge, because I regularly meet general practitioners and others in primary care.

Willie Rennie and other members attempted to set some context. The entire health and social care system—not just primary care—has been hit in the past few years by huge shock waves. In fact, there has been at least a triple whammy—there have probably been even more than three shock waves. Brexit has undoubtedly caused huge impacts, particularly in social care. I know that Willie Rennie recognises that. He was right, as were a number of other members. The convener of the Health, Social Care and Sport Committee, Gillian Martin, referred to social care, as did a number of other members. Social care has been hit particularly hard because of the impact and effect of Brexit. If members talk to any care home provider or those who represent the care home sector, such as Donald Macaskill, whom I spoke to yesterday, they will tell them about the enormity of the impact of Brexit.

Obviously, we have had the pandemic, as well, and there is no way that I could do justice to the scale of the impact that the pandemic has had. I completely accept that there were challenges pre-pandemic—I am not suggesting that there were not—but there is a world of difference between the challenges pre-pandemic and the challenges now. For example, pre-pandemic, we were not quite meeting the 95 per cent target for A and E; we were a few per cent—maybe 5 per cent—off. Performance now is not where I would like it to be: it is in the 60th percentile, and in England it is somewhere in the 50s. That is a world away from where we were pre-pandemic, so the scale of the challenge has clearly been impacted by the pandemic.

Willie Rennie

That is slightly at odds with what Paul Gray, the former chief executive of NHS Scotland, said. He said that this day was coming—it has been building for years—it is just that Covid brought it forward. Does the cabinet secretary not accept that?

Humza Yousaf

I do not think that what I have said is at odds with that, because I am accepting that there were clearly challenges pre-pandemic. There is a debate and a discussion to be had about how we reform our services while preserving that central ethos—which I believe in, and which Willie Rennie undoubtedly believes in—of ensuring that our NHS is free at the point of use.

However, I do not think that we know the full impact of the pandemic yet; we know only a certain amount of that impact. This goes back to a point that a number of members across the chamber made. We are seeing patients presenting—whether it is in primary care, which is rightly the focus of this report, or in secondary care—with a higher acuity level. That is, they are sicker and therefore need more complex intervention than perhaps they needed before.

The third shock wave that has hit our primary care services and, indeed, our whole health and social care system is the cost crisis, which has come about because of the UK Government’s complete mismanagement of public finances and the economy. High inflation is impacting public finances and budgets, and I would suggest that the cost crisis is actually a public health crisis.

We are now seeing that triple whammy hitting primary care. When colleagues—whether it is Sandesh Gulhane and Carol Mochan or others—challenge us on budgets, they are, of course, right to do so. That is, absolutely, the job of the Opposition. I want them to know that, as cabinet secretary for both health and social care, I do not take these decisions lightly. However, they are necessary, given that our budget is now worth £650 million less than it was when it was set in December last year.

If we want to pay NHS workers fairly, as I do, putting forward a record pay deal that is higher than the pay deal that is being offered in England and higher than the pay deal that is being offered in Wales, we have to be able to afford that. I heard Dr Gulhane speaking on the radio this morning, and he was challenged about where the money for that would come from. He was unable to say, and he started talking about the fact that we have apparently privatised rail, which is not what we have done—in fact, we have brought it into public ownership.

I agree with Carol Mochan’s point about vision, but I am sorry to say that, when I challenged her about what she said in relation to the budget, she was unable to identify a single penny that she would put towards that £650 million inflationary cost or, indeed, towards a pay deal.

I agree with members’ point about having a focus on the whole system, and I give an absolute guarantee that, when it comes to trying to alleviate the pressures on primary care and those alternatives, I hear what members are saying about the communication issue. That is a very fair point, which was made by the committee in its report and was well made by Emma Harper, by the convener of the committee and by many other members right across the chamber today. We can do more around communication.

Gillian Mackay was absolutely right in saying that we should go to where people are. We should make sure that we are on the platforms that they use and that we are in the places that they frequent. She mentioned using streaming services, for example, and we are considering what more we can do in relation to those, because I think there is no disagreement that those pathways are necessary and effective.

Many members raised the issue of social prescribing, and I give an absolute assurance that we are looking at the recommendations of the report. Maree Todd and I have asked officials to consider the point about a national lead for social prescribing. There is, understandably, a wide portfolio interest in social prescribing, but I am not opposed in principle to the idea of potentially examining and exploring the option of a national lead.

On the issue of a single electronic patient record—again, a theme that came up regularly from colleagues right across the chamber—I refer members to our Scottish health and care strategy. As the health committee’s convener highlighted very well in her speech, we intend to have medical records stored, linked and shared securely according to the information that is needed. In terms of how people will do that, we intend to publish a delivery plan in the coming weeks, and I will make sure that the plan is shared with members who have an interest in the area.

Many other points were raised, but—forgive me, Presiding Officer—I have not been able to cover them all.

I once again commend the committee for a fantastic report and thank members for their speeches today.

Thank you. I call Paul O’Kane to wind up the debate on behalf of the Health, Social Care and Sport Committee.


Paul O’Kane (West Scotland) (Lab)

I am pleased to close this important debate on behalf of the Health, Social Care and Sport Committee. In common with my colleagues across the chamber, I put on record my thanks to the committee clerks, support staff and all committee colleagues for their work and contributions to the inquiry and the report.

As we have heard in the debate, the inquiry has highlighted several challenges to the implementation of primary care reform and to improving access to and uptake of alternative pathways to primary care. We have had a good debate, and I thank all colleagues for their contributions, many of which highlighted issues in members’ local communities across Scotland and also noted where alternative pathways are proving successful, and where some are still struggling to take hold. It was important to hear the breadth and depth of what is happening across the country.

From our public survey, which was part of the inquiry, the committee heard that there were high levels of uncertainty among respondents about the availability of health practitioners locally and that very few respondents had self-referred directly to most non-GP health practitioners. We heard about some of that during the debate today. Members’ comments in the debate have shown that there are on-going issues with the uptake of alternative pathways to primary care.

Many members, particularly in the opening speeches, sought to provide something of the wider context, including Sandesh Gulhane, Carol Mochan and Willie Rennie. As Martin Whitfield said in his closing speech, we cannot get away from the context, and it is important to debate that, but we must ensure that we look at all aspects of what is going on in this space and ensure that we engage in a constructive manner.

I will turn to the Government’s contributions from Maree Todd and the cabinet secretary’s closing speech. I welcome the cabinet secretary’s written response to the inquiry and, indeed, his contribution to the debate, in which he, alongside Maree Todd, outlined the Scottish Government’s ambitions, the progress that it is making and the progress that it intends to make in the future. I know that the committee will continue to take a keen interest in the dialogue and in holding the Government to account on those issues. We have to ensure that patients can access the right healthcare professional in the right place and at the right time. I think that that front-door approach—

Gillian Martin

This leads on nicely from what Mr O’Kane has just said. Sometimes, members in the debate talked about diverting people away from GPs as the primary reason for alternative pathways, when it is actually about getting people the right care at the right time and with specialists who have the right equipment.

Paul O’Kane

That is important to acknowledge. Sometimes, it is difficult in this context to take a step back and understand that this is about holistic services and people getting support, because of the pressures that we know that GPs face. We heard from Maree Todd and others about the front-door approach and the no-wrong-door approach, and we have to ensure that that is at the heart of everything that we are doing—it is not simply about diverting patients from one place to another.

Many non-GP primary healthcare practitioners in Scotland are available to give patients the help that they need. However, as has been highlighted in the debate, there is still much to do to ensure that we reach that outcome. I recognise Martin Whitfield’s contribution on children and young people, and I endorse the convener’s intervention recommending that he look at the committee’s report on access to healthcare for children and young people, which I know he will do.

During the committee’s inquiry into the health and wellbeing of young people, we heard from young people who had encountered real challenges when trying to access support at a time when they were experiencing crisis, particularly with their mental health. Very often, we heard about problems that they had had with being believed or taken seriously. The ability to self-refer to a mental health professional would provide a lifeline for people in that situation and would enable them to get access more quickly and easily to the help that they need when they need it. It would also help them to not always feel overly medicalised in that space.

It was highlighted to the committee that mental health services were particularly difficult for patients to self-refer to and that self-referral was not an option in most health board areas. However, Dr Jess Sussmann of the Royal College of Psychiatrists told us that that is possible in Glasgow, where 46 per cent of referrals to primary care mental health teams are self-referrals. Those mental health teams can then assess whether the patient has a mild to moderate mental health problem or something more serious, in which case they would be referred to secondary care.

The committee believes that self-referral to mental health services is an important step, and that all health boards should be making that available. I see that the Minister for Mental Wellbeing and Social Care is in his place, and I am sure that he will be keen to engage with boards in that respect. To be fair, it is not without its challenges, but Glasgow has shown what can be achieved when it is done successfully.

The cabinet secretary told the inquiry that promoting self-referral to appropriate support is one element of the new multidisciplinary mental health and wellbeing services in primary care due to be implemented this year. The committee welcomes that commitment and looks forward to it becoming a reality very soon.

During the debate, many members spoke about the benefits of social prescribing. There were some excellent contributions on that. I highlight in particular Sarah Boyack’s passionate advocacy for therapeutic intervention through culture. We can all recognise something in that, including the importance of making it more mainstream and better supported.

I support all the comments on social prescribing. Many of the witnesses whom we saw in the committee identified significant potential for wider social prescribing, particularly for people who present with problems that are rooted in non-medical issues. However, again, the committee heard that a key barrier to the greater use of social prescribing is the reliability of information on services that are available locally. From members across the chamber, we have heard that broad theme about getting it right when it comes to how we communicate with people, how we tell them what is available and how we ensure that they have access.

Citizens Advice Scotland told the committee:

“Social prescribing is beneficial for a certain group ... the ‘savvy’ group, which is the group that is aware that self-care works and that social activities can help and can alleviate issues—but it does not seem to work for the other groups. That is down to a lack of public awareness ... if people knew what was available to them ... it might increase the uptake”.—[Official Report, Health, Social Care and Sport Committee, 8 March 2022; c 13.]

The issue of poor signposting was raised many times during the inquiry and has been raised again during the debate. Certainly, my committee colleagues Stephanie Callaghan and Gillian Mackay made strong contributions on that. We need to have reliable, comprehensive and up-to-date information about local and national services. That would greatly assist in the signposting of patients and would encourage greater use of alternative pathways.

We have had some contributions on ALISS—a local information system for Scotland, which is a database that is run by Health and Social Care Alliance Scotland and funded by the Government. In the committee, my colleague Emma Harper is always a strong advocate for its use and for interrogating the ways in which it—or local versions of such a library—could work better.

Although the committee recognises the value of such a database and sees the potential for ALISS to improve signposting, there are concerns about the constantly changing landscape of providers and non-GP primary care services, which may limit the reliability of the information that is available, and about the need for constant monitoring and updating. The committee believes that, through a significant improvement to the general awareness of ALISS among health practitioners and to the accuracy, reliability and comprehensiveness of the information that it contains, ALISS has the potential to become an authoritative source of data for those who seek to signpost patients towards alternative pathways to primary care. Our report calls on the Scottish Government to work in partnership with the ALLIANCE to undertake an assessment of the actions and associated funding that are required in order to achieve that, and I am pleased to note from the cabinet secretary’s written submission that he has since met the ALLIANCE to progress that work. We look forward to further information on that.

In drawing my remarks to a close, I again thank everyone who contributed to the debate, and I echo the convener’s words of gratitude for the contributions that we received during the inquiry. Despite, it is fair to say, the debate being sparky at times, we have managed to agree that we all share the principle of primary care reform: people getting care at the right time and in the right place. However, it is clear that, for that to happen, a number of important challenges must be overcome.

The public must have greater confidence that, in many instances, their GP might not be the first port of call, and that using an alternative pathway might give them quicker and easier access to the treatment that they need.

The option of self-referral needs to be more widely available and accessible, and better understood. Information needs to be up to date and available to all, both online and offline, because we cannot forget about a whole section of society that does not have access to the internet and still finds it challenging to access information in that space.

By addressing those challenges, alternative pathways have the potential to transform how patients experience primary care, because they shift the focus towards a more preventative approach, with quicker and better outcomes for everyone.

Clearly, today is not a full stop but a comma in our debate and discussion on those issues. We look forward to continuing to progress the report’s recommendations.