NHS Independent Scrutiny
The next item of business is a debate on national health service independent scrutiny.
I am pleased to open this debate about building confidence in the process of proposing and agreeing change to local NHS services.
Members will recall that we recently concluded a public consultation on the role that independent external scrutiny might play in that process and the form that it might take. The consultation was extremely successful and generated more than 100 written responses. My formal response and decision on the future role of independent external scrutiny in the service change process will be set out next month, but this debate is an opportunity for Parliament to influence that decision directly, and I will consider carefully all the points that members make before I reach a final conclusion.
I am sorry to stop the cabinet secretary so early, as she is getting into her flow. Will she give us fair warning when she is about to announce her response to the consultation, so that we can all respond to it effectively?
I give that assurance.
Before I take the decision, I will also reflect on the lessons of the successful applications of independent scrutiny in the NHS Ayrshire, NHS Lanarkshire and NHS Greater Glasgow and Clyde areas. In all those cases, we saw the value that independent scrutiny can add to the process and the positive difference that it is capable of making to outcomes. In the case of NHS Greater Glasgow and Clyde, it has led to important changes in the decision-making process and, in Ayrshire and Lanarkshire, it positively influenced the substance of health board proposals.
In all cases, public confidence has been enhanced, which is why I want to embed the value of independent scrutiny for the future. "Better Health, Better Care" commits us to a more inclusive relationship with the Scottish people—a mutual NHS, in which patients and the public are affirmed as partners, rather than as mere recipients of care. It means that the boards must develop the case for service change with the people they serve. The key principles of how that should be done are already set out in guidance. Briefly, that guidance states that proposals for service change should emerge naturally from a board's day-to-day engagement with the people it serves. Local people should be proactively engaged in developing options for change, and the scale of the public consultation should be agreed with local people and be proportionate to the scale of the proposed service change.
Although that approach cannot guarantee support for a proposal, it is intended to demonstrate that the NHS listens, is supportive and genuinely takes account of the views and experiences of local people. The Scottish health council has a key role to play in quality assuring boards' engagement processes. It does not pass comment on the strength of the case for a proposed change, or the evidence underpinning it. Public distrust of boards has been most obvious and acute around the reasons for change and the strength of the evidence supporting it; it is here, therefore, that independent scrutiny can enhance the process. The key purpose of scrutiny is to examine rigorously the evidence for service change and to provide an independent commentary on its strengths and weaknesses. That commentary can then inform option appraisal, consultation and decision making.
I want to address a thoughtful point that was made by Ross Finnie in an earlier debate. He said that if independent scrutiny had identified failings in boards, we should address those failings rather than embed scrutiny. With respect, that view somewhat misses the full value of scrutiny. It is true that the three reports so far have identified failings, and others in the future may do so, too. We should, of course, address those failings. However, it is not true that in every case in which the public oppose change and distrust a board, the board is wrong or has failed. Independent scrutiny may on occasion confirm the strength of a board's case. That is as important in building confidence as exposing weaknesses in the board's evidence.
I hope that I have clearly outlined the principle of independent scrutiny. Before I share my thinking on some of the more detailed issues of its operation, it is important that I repeat an important point. Independent scrutiny will not obviate the need for difficult decisions to be made. Proposing change to local health services is difficult to do, but sometimes it is necessary. A complex range of factors—clinical effectiveness; patient safety; workforce issues; finance; and the views of patients and the public—all have to be considered. Understandably, those finely balanced professional arguments can be difficult to understand and accept. There will be occasions when the evidence on some aspects of service change is inconclusive, or there may even be situations in which some of the evidence seems to point in different directions. However, decisions will still need to be made, and boards, quite rightly, have a responsibility to make a judgment in such cases.
Ultimately, proposals for major change in the NHS are subject to ministerial approval. Any board should have confidence in submitting proposals to me, provided that they have set out the arguments openly, fully and fairly; that there is the clearest possible evidence base for their proposals—or where there is not, that they have been open about that and made a persuasive case nevertheless; that they have listened to and reflected as far as possible the views of the public; and that the proposals are in line with our national policy direction. "Better Health, Better Care" sets out that policy direction. It builds on the Kerr report, but it also challenges old assumptions in the light of better, more considered evidence.
We operate a clear presumption against the centralisation of key health services—an approach that is entirely consistent with work emerging from NHS Quality Improvement Scotland and from international analysis from Europe and elsewhere on the relationship between volume and outcome. That analysis shows that while there can be an association between volume and outcome—between concentration and quality—there is no general rule. Each case must be considered on its merits and the evidence must be tested.
I am glad to say that the principle of independent scrutiny was broadly endorsed during the consultation. However, I want to touch briefly on three detailed questions. The first question is, in what circumstances should independent scrutiny operate? I want to be frank: it would be expensive, time consuming and impractical if scrutiny were applied to all proposals for service change. The benefits of independent scrutiny will need to be carefully weighed against the costs, on a case-by-case basis. Scrutiny should be applied only to cases of major service change.
At the moment, the Scottish health council is working on what constitutes major change, but subjective factors will always be in play. That is why the decision on whether scrutiny should apply should be left to ministers. It is a matter of judgment, but I intend to set the bar high.
The second question is, when in the process should independent scrutiny take place? The consultation paper proposed that it should happen before full public consultation, and there was support for that approach. However, when issues relating to the evidence emerge later—as was the case recently in Greater Glasgow and Clyde NHS Board—it should be possible to reconvene the panel.
Scrutinising the evidence early in the process helps to ensure that there is an agreed evidence base for the subsequent decision-making process, which will include option appraisal. It should also ensure that an option is not discounted without due consideration of its merits.
The third and final question that I want to consider at this stage is, what form should independent scrutiny take? Members will not want any unnecessary bureaucracy to be set up. However, we want the scrutiny to be effective. The majority of respondents to the consultation agreed that our preferred option—an external scrutiny panel—would provide the most effective form of scrutiny. The reason they gave was the evident strength of the approach, which lies in the independence and skill mix of the panel members. In the consultation, we asked questions on such matters of detail, and we are analysing the proposals further. However, detailed answers to all the questions will be set out when I publish—with due notice—ministers' final decisions.
The cabinet secretary has made some very important points. She mentioned the skills mix within the independent panels. According to the consultation document, panel members will be independently appointed, and it will be important that their remit is focused. Does the cabinet secretary agree that the panel's remit should be focused on the evidence? The Scottish health council is working on the consultation process, and the panels should not tackle the consultation process or we will get mixed messages.
I thoroughly agree. The delineation between the current role of the Scottish health council and the role of independent scrutiny panels is important. I have tried to emphasise that point.
It has become clear to me over the past few months that, if we are to avoid future public mistrust—which so clearly marked the original service reviews in the accident and emergency proposals in Ayrshire and Lanarkshire—we must develop the evidence for change with the public. Independent scrutiny will, I believe, build confidence in the decision-making process. It is not for those who undertake the scrutiny to make the decisions; rather, their job is to help build confidence in the evidence base that underpins those decisions. That, coupled with the reforms that are detailed in "Better Health, Better Care" to strengthen existing public consultation mechanisms, plus the possibility of there being elected health board members, will significantly reform and improve the process of consultation and public engagement. The NHS will be stronger and better for it.
I am glad to have had the opportunity to set out my thinking today. I look forward to hearing a range of contributions from across the chamber.
I welcome this debate, which is of key interest to many of us in the chamber and throughout the country—especially those who are engaged in the challenging delivery of NHS services.
I welcome the cabinet secretary's commitment to giving us warning of her decision. Obviously, we have a strong interest in that decision and I am sure that we will return to it in a parliamentary forum again. In the light of many of the comments that she made, we will want to test some of the issues and explore their practical implications and what they mean for the development of health services in Scotland.
I want to use my opening remarks to put some of the issues that were raised in context. At the core of this debate is an attempt to strike a balance between ensuring effective and efficient decision making for a service that matters a great deal to people, and ensuring a proper and robust process of decision making that enables people, especially the key stakeholders, to have confidence in the system.
It is easy for us to state in the Parliament that that should be the case, but the issue is complicated in the detail and challenging in the delivery. People in Parliament and in the wider body politic in Scotland—particularly health service professionals—have to appreciate that we live in an environment in which there is a profound commitment to the national health service and in which people have great loyalty to their local health services, and that we have a responsibility to lead change as well as follow it. That is true of all services in Scotland, but it is particularly true of the health service—health has a resonance that really grips people. Health is extremely demanding of resources and there is huge public loyalty and commitment to existing services. [Interruption.]
That is not my mobile phone—at least, I am pretty sure it is not.
Members should ensure that their mobile phones are turned off. One is switched on very close to Ms Curran's microphone.
I will move my bag, just in case.
Change is a constant in the area of health, in terms of technology, service improvement and debate. It is sometimes difficult to keep up with the changes, let alone meet the challenges. We must create an environment in which we are prepared to face and encourage change and not be frightened of it, even if, at times, there is resistance to that idea. Of course, that is not to say that change should be imposed on people and that we should never listen to voices that question that change. We must ensure that people are not frightened of change though, in a sense, we sometimes create forces that inhibit our attempts in that regard. Government has a key role to play. It must ensure that we create that balance between effective decision making and giving people confidence in the process of that decision making, without throwing the baby out with the bathwater and creating a system in which change is inhibited.
How do we get that balance? What is the mix of processes that will lead to people having confidence in the scrutiny of key decisions that are made? We have had this debate before in the chamber. Transparency and accountability are the common themes of the current debate, and there is obviously concern about those issues. I agree that there is a need to produce high-quality evidence and to test arguments. That is where some of the public debate must lie. Many people have argued against major service change because they have not trusted the evidence that was put to them. However, we must be careful that, in doing that, we do not set the bar so high that nobody could meet that evidence test. We must ensure that the evidence of those who give evidence behind closed doors is robust and that they are prepared to put that evidence into the public domain and engage with the public about their recommendations. We must have a broader democratic debate about, for example, some of the clinical arguments for change.
Furthermore, there is the issue of how independent the scrutiny can be and how we can ensure that it has genuine support. If independent scrutiny panels introduce an imperative that makes decision making better, ensures robust evidence, restores confidence to the decision-making process and ensures that it is not only vested interests that influence the process and make decisions—and that vested interests are subject to scrutiny and control—there is a strong case for independent scrutiny panels.
However, we must be prepared to examine the counter-arguments. Independent scrutiny panels cannot be used to endorse decisions that have already been made. We have to be upfront about that. They must have added value, and be used to improve decision making and, ultimately, the quality of service. There is a key link between the decision-making process and the outcome of the decisions. If the decision-making processes only serve themselves and do not ultimately lead to service improvement, they will not prove to be useful. They must be used to test clinical evidence and managerial decision making, and to bring to the fore, on a public platform, some of the arguments that have perhaps been used more privately in the past. I think that there would be support for that from members all round the chamber.
The scrutiny panels cannot be used as a force of reaction, they cannot create inertia, and they should not be used as a means of stopping change. As has been said, change will always be required in the NHS and we cannot be afraid of introducing it. However, vitally, we must bring people with us as we do that.
How will all that be achieved? As I understand it, the ministers' decision is still to be finalised. We must be seen to give real independence and accountability to the process, and we must raise the standard of public debate about health and all the factors that go with it. The Government needs to clarify a number of matters; perhaps that will happen as we move on from today's debate, but I hope that the minister will address a number of them in her response to the debate.
The Government has said—and I listened to the cabinet secretary's speech today—that independent scrutiny panels must ensure that health boards base their decisions on proper evidence when they make major service changes in local NHS facilities. It is imperative that we have clarity in what is meant by the phrase "major service changes". I was not sure what the minister meant when she spoke about a "case-by-case basis"; we need to know the criterion for that, how it would be determined, and who would determine it. I think that the Scottish health council would have a role in that.
The Scottish health council is considering the development of a tool that will help in making a decision on what is major and what is not. It has always been the case that such decisions—at the moment, only major changes must come to ministers for approval—ultimately rest with ministers. I ask Margaret Curran to accept that there will always be a degree of subjectivity. What might be a minor change in a large city would be a major change in, for example, a rural or island part of Scotland. It is therefore important that, in the final analysis, a minister can exercise a degree of judgment.
I accept that argument, but it is nonetheless important that if we suggest to people that we are introducing an element that can give them confidence about changes that really matter to them, and that we are introducing an element of independence into the process, we are seen to be doing that, rather than presenting the process as applying to some decisions only and not to others. NHS boards, the public and many local organisations that could be affected by the panels' decisions must be aware of when and how the scrutiny process will occur. We need a debate about how that moves forward.
If independent scrutiny panels are to educate the public, they must enable, facilitate and empower those who are affected to participate in a well-informed debate on the health boards' decisions. At this stage, we should not say that people are empowered only for some decisions and not for others, which are to be decided privately by the minister. If the Government goes down this road, it must face the full consequences. There is a current drive to make everything as public as possible; the Government must accept that it initiated that drive and it must live with the consequences.
It is important that the Government clarifies the panels' role in relation to public consultation. The review panel that was chaired by Dr Andrew Walker relied heavily on the Scottish health council—an authority that was set up by the previous Executive and which had the explicit goal of ensuring that the public are properly consulted on important NHS decisions. That element of consultation was vital. Without the help of the Scottish health council, the Walker panel could not have undertaken its work. It is vital that the Government clarifies the relationship with the Scottish health council.
The minister must today make abundantly clear the relationship of her policy with the presumption against centralisation. As a legal term, presumption has a very strong impact, particularly when it is viewed in a planning context. We must be clear on the role of the presumption against centralisation in that context. The minister should not present it as if all decisions will be independently verified if they will not be. There are still a number of details to be considered.
The Scottish Conservatives acknowledge at the outset of the debate that the Cabinet Secretary for Health and Wellbeing's decision, made on coming into office, to establish an independent scrutiny process has proved an unqualified success. Almost at the stroke of a pen, Nicola Sturgeon acted to restore the badly bruised public confidence in decisions on major service delivery change. Both the SNP and the Scottish Conservatives fought last year's election on a pledge to reverse the damaging closures of accident and emergency departments and bring to an end the seemingly messianic obsession with the centralisation of acute health services. That promise has been emphatically delivered at Ayr and Monklands hospitals.
The establishment of an independent scrutiny process was a bold step, but by ensuring that decisions are reviewed afresh by experienced professionals who are one step removed and take a broad view, public confidence in the conclusions that are reached has been restored. We owe a debt of gratitude to professors Andrew Walker and Angus Mackay and those who have served them so far.
The consultation on what future role an independent scrutiny process might have is appropriate, important and timely if public confidence is to be sustained. However, we should not lose sight of the reason why such a process proved necessary, because that should inform what happens next. The reason was surely the almost complete collapse of public confidence in the modern consultative process.
The public have become both wary and cynical of consultations, the outcomes of which appear to have been pre-determined. People's anger is aroused by the presentation of so-called options, many of which appear to have been drafted merely to be subsequently dismissed as either ridiculous or impractical. Indeed, several of the so-called options are often rubbished by the very organisation that has included them in its consultation. A clear impression is given that they exist as options only to reinforce the prejudice that underlies the preferred course of action of those who are consulting. That might be an unfortunate caricature of the actions of those involved but, to be frank, as far as the public are concerned the perception is the truth, even if it is not the reality. Even more unfortunately, it now appears that the perception was the reality in relation to the A and E departments at Ayr, Monklands and the Vale of Leven hospitals.
The modern consultative process is not unique to the NHS—for evidence of that, we need look no further than the Westminster Government's consultative process on post office closures—but it is particular to the NHS. During the past decade, many people joined consultations on major service changes in good faith and demonstrated the substantial public support that underpinned their local campaigns. It is no wonder that they recoiled in frustration and outraged disbelief when all that they had achieved was dismissed out of hand.
The previous Administration's record on the NHS is not without merit, but it suffered the public's disapprobation and contempt for its apparent arrogance in pressing forward with enforced major service change and never hesitating in the face of public anxiety or will. Perhaps ministers persuaded themselves that that was leadership. In response to the ministerial statement a fortnight ago on the decision to retain A and E departments at Ayr and Monklands hospitals, which arose from an independent scrutiny process, Andy Kerr vaingloriously railed against the fresh decisions that were reached, seemingly oblivious to the change in the public mood.
Labour supremacy in local government and at Holyrood is a thing of the past and Labour bombast and edict will no longer serve. Andy Kerr needs to wake up and smell the disinfectant and Margaret Curran needs to disassociate herself from what is a barren strategy and commit her party to supporting a future sustained role for both independent scrutiny—I think that she engaged in that in her comments this afternoon—and genuine public consultation.
Does the member accept that, following the 1999 Stobhill inquiry, interim guidance was issued in 2002 and a reform bill was passed that insisted on consultation? Does he agree that, although some consultations might have had flaws, that is partly because the Scottish health council was not established until 2005, by which time those consultations were under way?
No. As I said a moment ago, the public perception of some consultations that have been initiated on major service change—not just in the health service but elsewhere—has been that, although options were presented, they were not credible options and the organisations that were consulting sought to undermine the very options on which they canvassed views.
When the cabinet secretary launched the review, she said:
"Independent scrutiny will operate prior to public consultation on proposals for major service change and the conclusions will be reported to NHS Boards and Ministers."
Will she consider whether responsibility for ensuring that the options that are put are credible, and whether guardianship of any subsequent consultation process—one in which the views of the public are treated seriously—should be entrusted in future to the elected members of health boards? As long as they have access to advice to carry out whatever functions are bestowed on them, the public will be able to have confidence, knowing their obligation to ensure a proper and open consultation.
Whatever the future system, the existence of an independent scrutiny process has been vindicated. Indeed, given the decisions in Ayr and Monklands and on children's cancer services across Scotland, it is understandable that many in greater Glasgow now regret that the present Government was not in office when controversial change was forced on them. They are right to wonder just how safe that change will prove.
Although I understand and respect the cabinet secretary's pragmatic view that decisions reached years ago and now being realised cannot be subject to yet further review, I believe that there is a special case in greater Glasgow, which serves such a vast community, not for fresh independent scrutiny of the immensely complicated infrastructural decisions that were reached, but for an external review of their implementation and the opportunities for service enhancement that might be accommodated to mitigate a sustained public concern by communities currently served by Stobhill and Victoria hospitals that was voiced again at public meetings just last week.
We all appreciate that the management and running of NHS boards is a huge undertaking. Boards have to get on with it and cannot have some permanently seated quango ranging casually across Scotland, second-guessing their every decision. That would paralyse the NHS.
If we can ensure renewed public confidence in the consultation process, the need for later independent scrutiny of decisions should diminish. We should work to achieve that end. The public have responded positively to independent scrutiny, and they clearly have confidence in it. We should ensure that they are reassured that no future Government will in the final analysis abdicate its responsibility in a welter of self-justification, but will instead reserve to itself the means to scrutinise independently what is recommended. All parties now need to accept such a process, and the cabinet secretary can be assured that we will look positively at whatever proposals finally emerge.
No one has disagreed that we faced a position, which the cabinet secretary outlined, of a public lack of confidence in how health boards were reaching major decisions. We should not kid ourselves that the problem stopped there. Sadly, the public's confidence in health boards per se has been undermined in the process. What we face is the question of how to restore confidence both in health boards and, more specifically, in how they take major decisions.
As has been said, the major cause of the problem related to modernisation of the hospital estate and, in particular, the total lack of public confidence in the ability of health boards to carry out a public consultation that in any way appeared to take account of the public's views. Professors Walker and Mackay have extended those criticisms of how the boards operate. They have criticised boards' ability to introduce proposals that could stand up to robust scrutiny. They have criticised boards for being too ready to accept both arguments from the royal colleges for specialisation and data suggesting a shortage of specialists. They have criticised boards for being too quick to promote centralisation as the solution and for making unsupported assumptions about the ability of paramedics to stabilise patients before transfer and the safety of longer ambulance journeys.
That is all important, but we should remember that the proposals were drawn up by the executive directors of the health boards, who we believed had proper qualifications. They were supported by the non-executive directors as currently constituted. The criticisms of how the boards in question—and perhaps boards generally—currently operate are serious.
Does the member accept that an independent consultancy looked at the consultation process in at least two cases and in one case an independent individual—a pro-vice-chancellor of the University of York—looked at the evidence? Attempts were made by the health boards, albeit they were not successful.
That might be right, but I want to stick to the generality. There are serious issues facing the health boards in question and boards in general.
There is clear agreement that public consultation, patient safety, sustainability, sound evidence bases, value for money and rigorous and transparent public consultation are essential. The cabinet secretary's proposal, which she outlined clearly, is to embed permanently an independent scrutiny panel to oversee what is happening.
I am grateful to the cabinet secretary for considering the point that I made earlier. I do not think that I confused two issues and I will develop my point a little further. The cabinet secretary will remain the ultimate decision taker when big decisions are being taken. She and her department will rightly retain the role of setting the strategy for the provision of health care throughout Scotland and the local health boards are supposed to be responsible for the delivery of health care in their areas. The question is: will we totally restore confidence in those boards or leave a lingering doubt that they will be overseen by a third party when there are major changes? The cabinet secretary has argued the case for the former.
There will always be a case for any cabinet secretary to appoint independent scrutiny if they believe that the nature of a board or how it is performing gives rise to doubts about whether it can properly discharge its functions. That is different from the premise that a redefined, reformed and improved health board will start from the presumption that when major decisions are being taken, its decisions will be overlooked and second-guessed by some independent panel. That will give rise to difficulties in recruiting people of the right quality and calibre whom we want to serve at the top end of our health boards. I will return to the new proposals relating to non-executive directors. However, whatever road we go down, I ask the cabinet secretary please to take steps to sort the problems that have been identified.
Ross Finnie raises an important point. He is absolutely right. The independent scrutiny reports that we have received identified weaknesses that must be addressed in a range of ways. Many of our other proposals in "Better Health, Better Care" go some way towards doing that. However, does Ross Finnie agree that independent scrutiny potentially has a much more positive role to play than simply exposing such weaknesses? I will paint a scenario. Imagine a perfect health board that does everything right. When it proposes major change, the public will still view it with suspicion, because it will be seen as having a vested interest in the outcome of that change. Therefore, there is a role for independent scrutiny panels to quality assure evidence, in the way that the Scottish health council quality assures the engagement process.
I am grateful for the point that the cabinet secretary makes, but let us consider it, along with my final point. If there continues to be doubt about something and a need for the public to be satisfied by an independent body, what the cabinet secretary proposed will be brought into play. I do not entirely agree with its methodology, but I will not go into that this afternoon. The cabinet secretary proposes that the non-executive directors of health boards should have the clear confidence of the public because they are elected. What on earth is the point in having non-executive directors who will require support and training to ensure that they properly bring the executive directors to account in a way that, I accept, has never been done in the past, and then saying to the public that an unelected body will second-guess decisions? That will undermine the standing and status of the health board.
I remain open to further debate on the important subject of independent scrutiny, but I hope that we will consider further how reformed health boards, the problems of which have been sorted out and that have totally different elected structures, will restore confidence to the extent that we do not need the permanent embedding of independent scrutiny panels.
We now come to speeches from back benchers. I allowed a little leeway with the opening speeches, as we had a little time in hand. We no longer have time in hand, so I ask for six-minute speeches, please.
There will always be a balance to be struck in the health service between the desire to provide care as near to a person's home as possible and the quality of service, which might require its provision in a centre of excellence some distance away. Add to that the need to balance what individuals want against what the state thinks that it can afford, and it is no surprise that decisions are difficult to make. Sometimes, however, they are frankly wrong.
There are fashions in health as well as in any other area of activity and there are vested interests. Many years ago, a brave consultant at a hospital near where I worked argued that most antenatal care should be delivered in the community. His colleagues derided him, pointing to the pool of expertise that was available in a hospital and the inefficiency involved in specialists' having to travel to remote health centres. Yet, when he put his ideas into practice, antenatal care was not only delivered to a high standard; the outcome, in terms of healthy babies, was hugely improved. His critics had relied on gut instincts, whereas he used logic and triumphantly vindicated his stance.
We must admit that there is also a human desire among individuals—including hospital specialists—to associate on a daily basis with their own kind. On the positive side, that results in a symbiotic exchange of ideas and views, which is ultimately of benefit to the patients who are under hospital care. However, that undoubted benefit is negated if the result is treatment in a large hospital that is so far away from where they live that their clinical care is adversely affected. As I say, a balance must be struck.
So, who should strike that balance? So far, it has been the duty of the health board—a quango of executive officers and non-executive appointees. I have nothing but admiration for the vast number of people who are serving on health boards, who do their level best to maintain and improve health services in their areas; however, they do not always get it right. Sadly, as Jackson Carlaw has told us, the consultation procedures that they introduce sometimes seem to be more informative than genuinely consultative. The common perception is that although the boards ask for people's views, it does not matter what people say because the boards will have already decided what they want.
Is Dr McKee suggesting that the cabinet secretary's proposal to change radically the composition of the boards by introducing elected non-executive directors would not make a substantial difference to the situation that he has just outlined?
Having elected members of health boards would be an enormous improvement. One of the problems at the moment is the fact that no one in an area knows who their health board members are, and it is therefore difficult to regard them as representing people in the area.
Of course, there are occasions on which unpopular decisions must be made; however, people are not fools. If, for example, someone has a better chance of recovering from cancer by being treated in a highly specialised unit, they will not grudge the long journeys that are involved. Someone who lives in Fort William will not insist on going to the Belford hospital, for example, if they know that their treatment has a much better chance of success if they go to Glasgow for it. If they are shown the evidence and given a decent explanation, most people will accept such decisions. On the other hand, if they are just told that a local facility will be lost and they are not given a decent explanation, the result will be the kind of popular uprising that we saw after the decisions were made to close the accident and emergency departments at Ayr and Monklands hospitals.
That is why independent scrutiny of major health changes has a valuable role to play. There will be occasions—perhaps many occasions, as the cabinet secretary has said—when expert scrutiny of a controversial health board decision will result in that decision being upheld. Nevertheless, the decision must be based on evidence, rather than on fashion or whim. When a decision involves the closing down of local services, it must be clear to all why the presumption in favour of those services is being discarded.
In his speech in the chamber on 24 January, Dr Richard Simpson complained that the independent scrutiny body that criticised NHS Lanarkshire produced not a single piece of referenced evidence in favour of its determination; it simply restricted its role to criticism of the limited and flawed information base on which the health board had reached its decision. However, when a local service already exists—and there is a presumption that local services are best—surely it is up to those who advocate patients making long, tiring and inconvenient journeys to obtain treatment to produce the evidence for that being a good idea, not those who want to maintain an existing service. Until we have locally elected health boards—and we need to consider that again—independent bodies that scrutinise major decisions are the only way to restore public confidence in the health care decision-making process. I support that step.
I welcome the chance to hear members' views this afternoon. One of the key issues for me is the opportunity to read in detail the responses to the consultation that the minister said has now concluded. I have not had the chance to do that yet. I hope that we will all have a further opportunity to reflect on what each of us says today and on what we have learned from the consultation feedback. It is vital to understand why we are where we are. In the context of the outcome in Fife, Scotland is not a good place to be at all, although many people will take a different view on that.
One of the threads that runs through the work of the Health and Sport Committee and Parliament is the need for much better information. I hope that the minister will address that point carefully, because I am concerned about responses to parliamentary questions that say that data are not held centrally. If we are to take informed decisions on health matters, information is very important.
The Labour Party's view, as I understand it, is that there are arguments for and against the independent scrutiny panels, but I would like answers to some important questions. Under what circumstances will a panel be called in? What impact would that have on the outcome of any deliberations? For example, will a panel be called in only when the minister disagrees with the health board, as in the case of St John's hospital? Will the panel be called in before or after the health board has considered an issue? I know that the minister has answered that question to some degree, but she mentioned the possibility of an independent scrutiny panel sitting before a decision is made, and that situation could have all the difficulties that we had in Fife. The public get very sceptical—the public are sceptical about most things in life—and if people see an independent scrutiny panel agreeing with the health board, they will turn round and ask, "Is it a fix?" We must think about that very carefully. For me, the jury is out, which is why I would like to read the consultation responses.
There are also issues around the remit of the independent scrutiny panels. Will they be responsible for considering the evidence base for the local health board's decisions, or will they also examine the public consultation process? If they do both, will they then impinge on the responsibilities of the Scottish health council?
I answered that point in response to Richard Simpson. The Scottish health council's job is to quality assure the consultation. The envisaged role of the independent scrutiny panel is to do a similar job with the evidence base. The roles are clear and carefully delineated.
I respect that the minister answered Richard Simpson's question, but I want to read the consultation responses on that point. The minister has given her view but I would like to hear the Scottish public's response before our minds become too set on where we should be going.
Concerns have been expressed that the consultation processes that the panel has carried out so far have been flawed and less thorough in comparison to those undertaken by the health boards.
Ross Finnie made a first-class point when he talked about where we are going with directly elected health boards and independent scrutiny panels. Would panels decrease the power of local health boards? The SNP's support for direct elections to health boards lends weight to empowering health boards, as they would have members who are directly accountable to the public. Will ministers clarify their position on that? Ross Finnie made the point much more eloquently than I can and I agree with what he said.
If scrutiny panels are to be established, I agree that a non-clinical person should act as the chair of a panel. I would be happy to support that. That person would understand the scrutiny process and would be publicly appointed and accountable to ministers.
Above all, I hope that no attempt will be made to abdicate ministerial responsibility. I hope that no one will pass the buck back to independent scrutiny panels. In parliamentary debates and in the First Minister's answers, we often hear that something is a matter for local outcome agreements. The Government does not say clearly where the buck stops and how it will have measurable outcomes that reflect what we in the Parliament want nationally that will deliver for the people of Scotland.
There are many questions. I hope that ministers will give us the chance to have a further debate after we have reflected on what each of us has said today.
Let us be clear about the importance of the subject that we are debating. We are discussing not the advantages and shortcomings of service models, but a Scottish Government proposal that major changes to existing health services should be subject to independent external scrutiny. It is an important proposal that all members should understand would open up political decision making to unprecedented scrutiny. A mechanism would be put in place to ensure that when major changes to health services were planned, the public would have access to clear independent assessment of the bases for those changes.
It has been difficult in the past months—and perhaps it is even now—to work out whether some members of the previous Administration think that the proposal is good. It is even difficult to know whether a cautious welcome has been offered today—I do not think that even that has been given.
As she actioned for Monklands and Ayr, Nicola Sturgeon proposes, as a feature of decision making for Scotland's health services, to base such decisions on robust evidence—that term has been used quite a few times today—and to make them subject to clear independent scrutiny before they are implemented. That would ensure that the outcome of a change could be justified as being in NHS patients' interests.
From watching the mishandling over a long time of accident and emergency services in Ayrshire, I have a particular view of such events. I recall various presentations by Ayrshire and Arran NHS Board to East Ayrshire Council meetings at which the entire council opposed the board's plan to close Ayr's accident and emergency unit. The board did not estimate the number of people who would bypass Ayr hospital in an ambulance in an emergency or take any consideration of the concerns of relatives who faced travelling four hours or more to visit family members if they turned out to be in Crosshouse hospital near Kilmarnock. Such widespread public concern that was being ignored by a health board would be very much in the mind of an independent scrutiny panel.
The Ayrshire A and E services provide a case study of how the previous Administration conducted its business. As early as 1999, questions were being asked about the future of the A and E service at Ayr hospital. The then minister said that the health board had no plans to close the service, but events over the life of the previous Administration show the failure to keep the A and E service at Ayr up to date. That failure to invest was used as an excuse for closing the service, hugely against the local population's wishes.
As the independent scrutiny report on the Ayrshire A and E proposals makes clear, the health board has pursued solutions based on selective reading of international—and in some cases old—evidence of the impact of particular service models. The national framework for service change contained fine words about developing options with people, not for them. As the Cabinet Secretary for Health and Wellbeing said, it is important to stress the partnership role of all users of the health service rather than only the direct recipients of the service. The scrutiny panel found little evidence that that had been done. Those of us who experienced at first hand the anger of the people of Ayrshire at the way the change process was being handled could have told the scrutiny panel that, had we had the opportunity to do so.
Setting up independent scrutiny panels is a positive step for decision making in the NHS. The terms of reference for the panel that was set up to look into Ayrshire and Lanarkshire A and E services has been attacked. The panel was asked to ensure that services are safe, sustainable, evidence based and represent value for money. It was also charged with ensuring that services are robust, patient centred, and consistent with best practice and national policy. An important part of its remit was to ensure that service planners take account of local circumstances and the views of individuals and communities. Those strike me as appropriate tests to apply to new services. Perhaps most important, in the light of the experience of the Ayrshire A and E review, the public should be confident that all viable service options have been considered, including those that start from a basis of recognising the strengths of local services and community links.
The outcome of the independent scrutiny process has been warmly welcomed, not least by Ayrshire and Arran NHS Board, which now sees a clear way forward in developing services for its community. I am confident that the Government's proposals will be warmly welcomed by NHS professionals, patients and the wider community.
While preparing for the debate, I looked back over several debates on service changes proposed by health boards in many parts of Scotland. They do not generally make very happy reading.
In 2004, we heard the fears of the people of Caithness that a predicted loss of their consultant-led maternity services would result in mothers having to travel more than 100 miles to Inverness, on poor roads, often in bad weather, or stay in bed-and-breakfast accommodation or hospital wards immediately before their expected delivery date. Fortunately, active campaigning resulted in common sense prevailing, as when services were retained at the Belford hospital in Fort William, which has a proud record of trauma management.
The Vale of Leven hospital was not so fortunate. In the two years following the closure of maternity facilities there, 11 mothers gave birth in ambulances en route to hospitals in Glasgow or Paisley.
In April 2005, many of us attended an excellent public debate on reshaping the NHS, which was attended by patients, campaigners and NHS professionals across the spectrum. It became obvious that people want a safe, accessible and sustainable NHS that is delivered locally wherever possible. Centralisation was accepted as necessary for highly specialised treatments only. There was a clear demand for more meaningful public involvement in the planning and organisation of services.
People wish to retain local services wherever that is possible, especially in more remote and rural areas where, over the years, facilities have developed around communities. The hope was expressed that the Government would listen to the voice of local people and work with them to achieve a health service that was able to respond to all who wished to use it, that would be the pride of Scotland and that would give satisfaction to all who worked in it.
The Kerr report backed up those aspirations: it recommended that health care be delivered as locally as possible. But, by 2006, in the wake of Kerr, it was obvious that there was widespread concern about some proposed reconfiguration of health services. Some changes were welcome, but others—such as the well-known proposals to close A and E units at Monklands and Ayr hospitals—provoked intense and sustained campaigns against them. Those campaigns had the backing of politicians of all parties and of local people. They also had medical opinion on their side. Similar campaigns in the Borders put a strong case to ministers to retain hospitals in Jedburgh and Coldstream. Unfortunately, they were not successful.
In Grampian, there were active campaigns to retain maternity services in Aberdeenshire. Local people branded NHS Grampian's consultation merely cosmetic. That view was supported by the Scottish Health Council, which initiated further consultation. Only after that—and the further lobbying of ministers—was agreement reached to retain the capacity to give birth at Aboyne and Fraserburgh hospitals, which gave a measure of choice to the mothers-to-be who did not wish to travel many miles to give birth in Aberdeen.
We all agree that the public has a right to be consulted about major service change. Such consultation must be genuine and meaningful. When whole communities feel that that is not the case and responsible elected members of all parties support local opinion, ministers should be wary of taking decisions that are contrary to that weight of opinion.
Such decisions were not uncommon in the previous Administration. Often, public opinion was heeded only after strenuous local campaigns that cost a lot of time, effort and—sometimes—cash. The result was cynicism and a public perception that the Government was hell-bent on centralisation. Far from local people being involved in service redesign, they were brushed aside and ignored.
The Cabinet Secretary for Health and Wellbeing's decision, soon after coming to office, to set up an independent scrutiny process with regard to A and E services at Ayr and Monklands was very welcome and it has already gone some way towards restoring public confidence in decisions on major changes to service delivery. I welcome the consultation, which has just finished, on the establishment of an independent scrutiny system and concur with the British Medical Association's view that an expert panel might well prove to be the most effective way of providing independent scrutiny of proposed options for significant operational change and that such scrutiny must not only be evidence based but focus on the criteria of safety, sustainability and value for money for NHS boards.
I agree that panel members, however they are selected, should have the skills, experience and stature to inspire public confidence and that their findings should be put into the public domain. Such an approach should go at least some way towards increasing public confidence in how changes are progressed. If the health service is to be responsive to increasing demands and improvements in technology, there is no doubt that change will be required and that, at times, very difficult decisions will have to be made. In such cases, independent scrutiny of proposals will restore public faith in the consultation procedure and help to gain co-operation when necessary changes have to be implemented.
I hope that the consultation, the responses to which are currently being considered by the Government, will lead to a process that gives the public confidence that proposals for service change are indeed in the best interests of the communities at their receiving end.
I do not profess to have any detailed suggestions on how an independent scrutiny strategy might be implemented, but I look forward to the Government's proposals with great interest and an open mind.
After reading the consultation document and some of the responses to it, I support the concept of independent scrutiny that has been outlined and am inclined to support the third option. As it makes clear, such an approach is not entirely new. Indeed, the first sentence in the section that outlines the third option says:
"The NHS has used the approach of an independent, expert panel a number of times in the past",
and it gives the example of the group that reviewed maternity services in Glasgow—which, as it happens, I announced in a parliamentary debate in 2004.
Independent scrutiny represents another step towards establishing an open and effective procedure for bringing about service change that is based on developing options with people, not on presenting options to them. It is fair to say that such an approach has been evolving over a number of years and that, as I say, this is the next stage in the process.
Some NHS boards have been much better at this type of approach than others. Returning to the example of maternity services in Glasgow, I felt that there was great frustration that direct intervention was possible only at the end of the process. It would be useful to be able to intervene before formal consultation takes place—although I realise that under the proposals such intervention would be made not by the minister but by the scrutiny panel. That is consistent with the approach that was adopted in the Kerr report, which said that all options for service redesign must be considered before centralisation on grounds of resource or workforce constraints is considered.
A key question for a scrutiny panel is whether all the options have been examined. In relation to the Vale of Leven hospital, the scrutiny panel recently said that all the options had not been properly considered, which was a reasonable intervention at that point. The scrutiny panel's key task of assessing whether all the options have been considered is part of its more general commentary. It is useful to have a check in the system at that point, which will be crucial in giving people more confidence in the process, and it might potentially lead to a wider range of options being available—I say "potentially" because there might be little need for comment if a health board has done its job properly.
In my day, I always used to commend Tayside NHS Board and lament the fact that other health boards did not engage the public and put forward options to the same extent. If they had, the whole process would have proved much more successful. Perhaps we should hope for a withering away of the scrutiny panels in time, as boards get better at producing a range of options with a comprehensive evidence base.
Part of the purpose of the debate is to ask questions. Margaret Curran and others have done that, and I am sure that the minister will reply to them. An obvious question is about the nature of the panels. As it happens, last night, I asked a health activist in my constituency what she thought of them. Her response was that it depends who is on them. That is a crucial issue, although the way of forming the panels that the consultation recommends seems entirely reasonable. It might be desirable for a wider range of groups to be approached on the nomination of panel members but, apart from that, the general approach seems right.
There is also the issue of the degree of change that will be referred to panels. People have asked about that in the consultation responses and elsewhere, and the cabinet secretary has substantially addressed it. It is vital that there is clarity on the respective roles of the Scottish health council and the expert scrutiny panels. In general, people seem content with the proposed arrangements, but there might be an issue if boards work collaboratively to develop options for change. Will the scrutiny panel look only at the options, or will it look at how they have been developed? That question might already have been answered, but I have no doubt that it will be dealt with in the summing-up speech.
The key question is what happens when the evidence is contested. Page 12 of the consultation document says:
"The board would be able to reflect their conclusions"—
the panel's conclusions—
"in the final proposal for public consultation."
Does that suggest that the board can take or leave the panel's recommendations? A few questions remain to be answered but, in general, as the consultation responses indicate, there is overwhelming support for the external scrutiny process and I am happy to lend my support to it.
I welcome the debate and the introduction of independent scrutiny panels. I fully agree that every circumstance must be examined on a case-by-case basis and that the independent scrutiny panels should examine proposals before they are put out to full public consultation.
Every member will have their own experiences of health board consultations. As a West of Scotland MSP who stays in Inverclyde, I can assure the Parliament of the Inverclyde public's lack of confidence in the former Argyll and Clyde NHS Board. There is now an attitude of healthy scepticism towards Greater Glasgow and Clyde NHS Board.
It is obvious that the Parliament wants a strong, successful NHS. One way of ensuring that we take the public along with us is to ensure that the mechanisms are in place that will allow us to restore confidence in health policy decisions. I am sure that the introduction of independent scrutiny panels will aid the achievement of that aspiration.
The only constant in the delivery of public and private services is change—no change in the NHS is not an option—but if changes are proposed, it is vital that all the facts and figures and every conceivable piece of information be made available. Consultations that do not enjoy public confidence are not worth the time and resources they take up.
I was delighted that the cabinet secretary established an independent scrutiny panel to consider maternity services in the NHS Greater Glasgow and Clyde area. I took part in the consultation by attending a public meeting and providing a written submission. I also met panel members when they came to the Parliament.
When the panel reported, it suggested that the board maintain community midwife units at Inverclyde royal hospital and the Vale of Leven hospital. It suggested that the CMUs be maintained for three years, to provide a community education programme. I welcomed that suggestion, as did other people, but the board rejected it and still intends to remove vital services from the IRH and the Vale of Leven hospital. Two important points arise from that experience: the strength and status of independent scrutiny panels; and the continuing lack of public confidence in health boards. Ross Finnie talked about that in detail.
I agree with Ian McKee that the provision of evidence in consultations is vital. The public might not always agree with the outcome, but it will help if people can be taken along in the process. Independent scrutiny panels will provide a useful mechanism for holding health boards and the Government of the day to account. I hope that public confidence in health boards will improve as a result. If the public have no confidence in boards or other public service providers, we have major problems. It is imperative that the Government of the day get things right. I know from my experience in Inverclyde that public confidence is at a low ebb.
Independent scrutiny panels must fully consider comparative models in other health board areas. When the independent scrutiny panel considered NHS Greater Glasgow and Clyde's proposals for maternity services, I put forward information about NHS Tayside and the CMUs in Montrose and Arbroath. The information had not been brought to the panel's attention until then, so it was important that it was provided.
I agree with the presumption against centralisation. Services should remain as local as possible, provided that they are safe and viable. I am sure that the establishment of independent scrutiny panels will go some way towards ensuring that that happens.
I welcome the opportunity to take part in the debate and I welcome the consultation and discussions on independent scrutiny, which I am following closely.
The health of the nation is important. The health budget in Scotland grew by almost 40 per cent between 2000 and 2007, to about £11 billion, so it has a big impact on people's lives. A number of issues must be tackled: our population is getting older; we have made progress on the big three—cancer, heart disease and stroke—but much work remains to be done; and we must continue to consider health inequalities. There are big issues in Glasgow and central Scotland to do with how we tackle the health of people who live in areas of social deprivation. We must consider independent scrutiny against that background.
Major decisions about accident and emergency and primary care services will continue to have to be made. When such decisions are made, emotions run high. We need to balance communities' and patients' requirements with clinical requirements. Independent scrutiny can be useful in pulling together and balancing all those points of view, but it is important that that role is not pre-empted in any way, as has happened in recent cases. Independent scrutiny panels must be set up correctly. As Malcolm Chisholm rightly said, that is in part about organising efficiently the process of appointments to panels. We need the correct level of expertise and a proper vetting process. We need to balance clinical and community interests and we need transparency in the appointments process. Overall, scrutiny panels need accountability, so that people do not feel that their views are being ridden over roughshod.
Once a panel has been set up, it is crucial that the process is absolutely clear so that people know what job the panel is undertaking. The process should be logical from start to finish and people should be aware of what will happen at each stage so that, at the end of the process, whatever decisions are taken, the various parties feel that the process has been followed fairly.
Important points arise about evidence and data gathering. I do not agree with some of Ian McKee's points about presumptions and proving a case. It is incumbent on independent scrutiny panels to collect relevant data and to ensure that they are accurate, so that they can make decisions. Recently, several decisions have been criticised because they were based on out-of-date data or, in some instances, not enough data.
A big issue is the fact that these matters are complex. Stuart McMillan mentioned modelling, which is often used. A lot of data are fed in, assumptions are made and scenarios are built up—the process can be complicated. It is important that that part of the process is explained properly to the public, politicians and professionals, so that people are aware of the impact of the modelling and the outcomes of that process. That part of the process can be important for the ultimate decisions, so it is important to get it right.
Health is a major issue in the 21st century, so it is important that, if we go down the independent scrutiny panel route, we get it absolutely right. The process must be fair and transparent. The correct appointments must be made, the process must be clear and there must be a correct balance between health care, communities and professionals. I acknowledge that the debate on the advantages of independent scrutiny is on-going. I am listening to that debate and I will continue to follow it with interest.
This has been an interesting and free-thinking debate. I hope that I am right that the Scottish Government has not firmed up its opinions, although the cabinet secretary laid out her position clearly. She pointed out that the recent public consultation has been completed and gave her view that independent scrutiny has recently played a successful role. She made the important point that local people's involvement will be crucial in the future. She also mentioned the public distrust of health boards the length and breadth of Scotland, on which almost every other member in the debate touched. That distrust is unfortunate, but I accept that it is probably a fact. I was struck by the cabinet secretary's remark that independent scrutiny, whichever way we decide to go with it, does not equal avoidance of difficult decisions—an important point.
Margaret Curran reflected that point when she said that decision making must be robust and that we should not be frightened of change, locally or nationally, because that would be a dereliction of duty that would lead to atrophy and which would fossilise the health service once and for all, when it should be a changing scene. Margaret Curran also rightly made the point that the Government has a role. The cabinet secretary mentioned in her speech that, ultimately, ministers will rightly play a central role.
Many speakers touched on centralisation. Jackson Carlaw made the great statement that there is a "messianic obsession with … centralisation". I am not sure that that is absolutely true—I will touch on that in a second. The need to sustain and win back public confidence and the fact that the public are wary of consultation are points that echo with us all.
Members asked who should be involved if we go down the independent scrutiny panel route. If I am permitted, I will digress briefly on what Nanette Milne said about my constituency. When it came the decision on whether maternity services would continue to be delivered in Caithness and whether patients would be transported many hundreds of miles through snow to Inverness, one of the problems that we faced was that we had a kind of independent scrutiny in the shape of Professor Andrew Calder, whom the health board brought in to examine the issue. His conclusions were not helpful in any way and failed to recognise some of the key issues, such as remoteness, ambulance travel and inclement weather. If we go down the independent scrutiny panel route, the membership of the panels will be crucial.
One of the factors that bedevilled us in Caithness was the perception that Highland NHS Board was Inverness-centric and did not include representation from some of the remoter areas. That was a continuing problem that engendered suspicion and will have to be examined.
Ross Finnie argued—I totally support him—that a general lack of public confidence is undermining the present health boards, and that we should tackle that problem at source and seek to build confidence in them. Jackson Carlaw made the interesting argument that, when health boards work, the need for independent scrutiny will disappear. Perhaps Dr Ian McKee was alluding to that when he said something similar at the conclusion of his speech.
That somewhat begs the questions: why do we need to embed independent scrutiny at this stage if we recognise that the health boards are wrong and that, once they are put right, we will not need it and why not put the health boards right sooner rather than later? That was the main thrust of Ross Finnie's argument. The Liberal Democrats remain unconvinced that independent scrutiny should be embedded in the structure of the NHS. As Ross Finnie said, to do so would leave a lingering doubt about the ability of the health boards. I say to the cabinet secretary that I am not seeking to be contentious on this point—there is a genuine dialogue to be had on it. However, the image of an unelected body second guessing new health boards that have a democratic element would leave me deeply concerned.
Today's dialogue has been useful, but we must continue to explore the matter during the weeks and months ahead. I hope that what we ultimately decide collectively will be what is best for health in Scotland.
This has been a good debate. I welcome the constructive speeches from the Labour Party members, including Margaret Curran and James Kelly, who made an excellent speech.
Jamie Stone omitted to tell members that the independent scrutineer who examined the Caithness maternity services never travelled up the A9. He tended to fly into Wick airport, as I remember. If anyone is to scrutinise health services in Scotland, they need at least to travel by road.
Jackson Carlaw—my colleague—talked about credible options being proposed. That is critical. We have all seen health boards in the past argue for one favoured option. Independent scrutiny panels can scrutinise only the proposals and options with which they are presented: we should not expect them to come up with other options by themselves.
My second point concerns an issue that was raised by Ross Finnie about the timing of the independent scrutiny panels against the background of directly elected health boards. Asking unelected independent scrutiny panels to challenge elected health board members could present difficulties. Maybe—just maybe—we are setting the precedent for independent scrutiny of major change in local government. I am not sure whether our councillors would be too happy about that. The consideration of panels should take into account the fact that a number of health board members may be directly elected.
I have some further points for consideration, including an issue that was mentioned by the Cabinet Secretary for Health and Wellbeing. I understand that more work is being done on major service change. The Convention of Scottish Local Authorities and others raised that point in the consultation. What is the definition of "major service change"? For example, Orkney and Shetland NHS Board may decide to reduce a visiting consultant's time on the islands. That would not be considered a major service change, but to people living in the northern isles, a trip by air or ferry to Aberdeen for a check-up is a major change. [Interruption.] I am being constructive. A small change for a health board could be a major change for patients.
My second point is on the evidence for change. I am concerned about the scrutiny panels taking into account—or not, as the case may be—the cost implications of their decisions, and which services may be cut as a result of decisions and recommendations. To an economist, that is the opportunity cost. A major change proposal, examined by the scrutiny panel, could lead to cutbacks in services that are not considered to come under the heading of major change. For example, retention of a service could have severe implications that might lead to cuts in areas such as podiatry and physiotherapy, but it could also undermine service development, for example in cardiac rehabilitation. The independent scrutiny panels do not just need to look at the options in front of them; they need to know the cost implications of the options. I understand that the panels have to take into account value for money, but do they also have to take into account cost pressures and efficiency savings—which I agree with—that face health boards? That is a central question, especially given that people who will be affected by changes need to understand that the recommendations that will be made by the independent scrutiny panels can be overturned by boards and ministers.
Mary Scanlon has made a number of interesting points, but does she accept that it is not envisaged that independent scrutiny panels will be asked to take decisions for boards or to substitute their decisions for those of boards? They are being asked to assess whether the evidence that underpins the proposal is robust and whether all legitimate options have been properly considered.
I appreciate that, but if the public hears an independent scrutiny panel saying, "This evidence is robust. This is good. This stands up. This is what the public wants", its expectation is that what is favoured by the ISP is what will happen.
A crucial point is that the overturning of the recommendations of independent scrutiny panels by boards and ministers could lead to conflict between the proposals of independent scrutiny panels and those of health boards. That would be in no one's interests.
As many members have said, we must acknowledge that change is not always bad. It may not be what we are used to—it may not be what it has aye been—but innovation and change in service delivery can be necessary and beneficial. We should not assume that an independent scrutiny panel is a block on change. MSPs need to be positive in supporting local changes.
I want to raise a point that was first raised by Highland NHS Board. When summing up, will the minister confirm whether the Government will fully fund the independent scrutiny panels, as opposed to the health boards having to fund them?
In responses to the consultation, NHS Highland asked how the conduct and effectiveness of the panels would be monitored and assessed. NHS Lothian asked whether more of the scrutinising role could be given to Audit Scotland. That is worth considering. I hope that those and other questions will be answered when the Government analyses the consultation responses.
The problem that we face has arisen because of the historical situation. Until about 2000, when the Parliament really got going, a culture of paternalism, secrecy and disdain for the public, the patients and even the staff was evident in the process of producing major change. As Ross Finnie said, significant damage has been done to the public's confidence in our ability to achieve major change.
The previous Government tried to respond to the situation. There was interim guidance on consultation in 2002. The landscape was decluttered with the creation of single territorial health boards—the number of boards was reduced from 42 to 14. Local authority representation on health boards was introduced, in order to give a degree of local accountability. Partnership forums were set up, so that staff were represented on the boards. Then there was the embodiment of reform in the National Health Service Reform (Scotland) Act 2004, which led to the setting up of the Scottish health council.
As the cabinet secretary said, we need to be clear about the specific roles of each of the organisations. If we reclutter the landscape with a vast variety of individuals, who will produce competing opinions, we will be no further forward in improving public confidence.
The Scottish health council appeared only in 2005, and it gave a post hoc commentary on the consultation process in Lanarkshire and in Ayrshire and Arran. It made significant criticisms in both cases. Jackson Carlaw mentioned one particular criticism, which was that the boards narrowed the options before even starting the consultation process. In one instance, the status quo was removed from the possible options. Jackson Carlaw also pointed out that, in other instances, the boards produced options that were not credible and would have been dismissed out of hand in the first round of consultation.
We need an independent body that considers the consultation process, and we need the Scottish health council. The question that is before us today is this: Do we need the independent scrutiny panels to examine the evidence? Before we can answer that, we have to decide at what point an independent scrutiny panel—whether it be an expert panel or any of the three possible options—would actually examine the evidence. If scrutiny were always post hoc—after the board had chosen its preferred option—confidence in the board system would not be restored but would be further undermined.
The evidence must be considered at the outset, which is also when the consultation process must begin. The board should say, "This is the problem about which we want to consult the public", and the board could then give options X, Y and Z, based on evidence A, B and C. The independent scrutiny panel would then consider the evidence that the board had produced, and possibly say, "Yes, that is a reasonable body of evidence for the changes." The Scottish health council would consider the proposed consultation process.
Does Dr Simpson accept that that is exactly what we are suggesting? I think that the cabinet secretary laid that out quite clearly.
Yes—I am not criticising the Government's position. I am merely saying that it is not correct, as some members have assumed, that the independent scrutiny panel will come in later.
All members in the debate have agreed that change is inevitable. I have already said that all options must be consulted on, not just a few. I believe that the problem, not the options, should be presented first. Members have referred to the fact that there should be transparency at every stage. Change has to be evidence based and sustainable. It must improve health, and I believe that it must do so significantly. That is where the balance of judgment comes in. Change must be driven not by provider needs but by the evidence that is presented and the scientific data that are available. It should take into account issues such as transport and inequalities in health, which some of the consultations have failed to pick up on.
We need to recognise that some of the decisions that we will be faced with in the future will be balanced decisions and that the decision that is reached will depend on which experts have been asked to contribute. Mary Scanlon and Jamie Stone referred to the Andrew Calder consultation. In that case, an erudite and respected man came up with proposals but failed to take into account the fact that some people must travel down a pretty difficult road to get to Inverness to give birth. There is expert evidence and expert evidence.
We need to know whether the independent scrutiny panel will replace the consultancy reviews that are undertaken by boards. A number of boards have appointed independent reviewers to check that the boards' evidence is robust. I presume that those people will not be necessary if we have an independent scrutiny panel.
Malcolm Chisholm and others referred to the need for a skills mix in the independent scrutiny panel, but who will decide on that? The process must be robust. The appointments cannot be made by the minister in a political way. I know that that is not the intention, but it must not happen.
When would the panel be brought into being? The cabinet secretary has indicated that that would depend on whether the change was major and also said that what might be a major change in one area might not be major in another area. However, we must be clear about the criteria, because we cannot have independent scrutiny panels brought in because there is a public campaign or a lot of noise around an issue.
Could Dr Simpson outline the criteria that were operated by the previous Government and this Government about what needs to be called in by a minister for approval? At the moment, the same subjectivity applies.
As the cabinet secretary herself said, the Scottish health council is working on the criteria that define major change. I am just saying that we need to be clear in respect of establishment of the independent scrutiny panel.
We are all concerned to maintain public confidence. Whatever system we end up with must inspire public confidence. However, that does not mean that the outcomes will satisfy everyone: indeed, the Scottish health council's report on the situation in Lanarkshire said that it has no role in commenting on the desirability of the options and that the decisions that might be reached might not be the ones that the public think are best. Sustaining public confidence does not obviate the need for taking difficult decisions.
The most important problem is the cluttering of the landscape. If we are to have a substantial number of local councillors involved in community health partnerships and boards, directly elected health boards that are democratically accountable to their constituents, and Parliament and the minister, we must handle the involvement of the independent scrutiny panel carefully if we are not to end up in significant difficulties. There could be conflict rather than conflict resolution.
We need independent scrutiny of evidence. That must be in place in order to ensure public confidence. However, the timing of that scrutiny, the timing of the appointment of the panel, the timing of its intervention and the way in which it intervenes are all matters that must be clarified before a final decision is reached.
I thank members for their contributions to a very constructive debate and I reassure them, as the Cabinet Secretary for Health and Wellbeing did earlier, that those contributions will help us to decide on the form of independent scrutiny that will be applied to proposals for major changes in local NHS services. As the cabinet secretary stated, she will make an announcement on the detail of the process next month—she gave an assurance to Margaret Curran on that. That will allow us time to reflect on the points that members have made today—to which I will return—and the valuable lessons that are to be learned from the recent independent scrutiny panels in Ayrshire, Lanarkshire and Clyde.
I have heard members on all sides of the chamber agree that NHS boards must work with local people and communities to rebuild the public's confidence in developing service improvements. The cabinet secretary set out some of the key messages that have emerged from our consultation and which have been echoed in the debate. Boards must present clear evidence-based arguments about the need for service change before they develop options—a point that I raised in my intervention on Richard Simpson.
Boards must proactively engage local people at the earliest possible stage of the change process and work with them to develop proposals for service improvement. It will be important that they be guided by a general presumption against centralisation. The starting point for decisions on delivery of health services has to be that the NHS is a public service: a service that is used for and is, of course, paid for by the public—a mutual NHS. Boards must take full account of local circumstances in reaching decisions about service improvement, and must seek and take on board the views of local people.
Independent scrutiny will provide a way to improve existing processes to ensure that comprehensive information and advice are available to inform public debate. However, boards should inform and engage with local communities day to day, and proposals for service change should, as far as possible, emerge naturally from such engagement with the communities that they serve. Today's debate has included discussion of the recent examples of independent scrutiny panels in Ayrshire, Lanarkshire and Clyde, and consideration of some of the wider issues concerning national planning of health services in Scotland and how independent scrutiny will work in the future.
I will reflect on and respond to some of the issues that members have raised. Margaret Curran asked for clarity on what "major service change" means. Mary Scanlon and other members asked similar questions. As the cabinet secretary said, the Scottish health council is developing a tool to help to define major change, which has to take account of the fact that a major service change might be different in a remote and rural area than it would be in an urban setting. The decision will ultimately rest with ministers and their judgment. It is already the case, as the cabinet secretary said, that some decisions come to ministers and some do not. That is not a new concept. There will always be an element of judgment, but the important—and new—thing is that we are introducing independent scrutiny into that process.
I accept the logic that the minister has outlined, but will ministers make clear the criteria on which they judge whether decision should go to independent scrutiny that?
Yes, of course. That is part of what the Scottish health council is working on. Ultimately, such decisions will always be subjective. We can lay out the criteria that lead to a decision, but they will always be subjective and will differ depending on the setting. We will require such flexibility. Margaret Curran also asked how the presumption against centralisation links in to the independent scrutiny process. A clear policy context to that is set out in "Better Health, Better Care", within whose principles health boards should operate when they propose service changes. They do not operate in a policy vacuum.
Ross Finnie talked about plans that are drawn up by executive directors and supported by non-executive directors, the implications for how boards operate, and the possibility of their being challenged. Changes are required to the ways in which boards operate, of course, and lessons have to be learned. Everybody accepts that. Health boards and others should take steps to improve the ways in which they go about their business, and that is happening already. Direct elections are part of that improvement, but they are about more than that: they are about better governance more generally. The independent scrutiny process will quality assure the evidence that is to be presented, just as the Scottish health council quality assures the consultation process. The aim of that approach is to rebuild, improve and build up the public's trust in the health service.
Malcolm Chisholm asked what would happen if a board ignored a panel's comments. It is important that the cabinet secretary would consider that as part of her deliberations, given that the final decision is to be made by her. However, we do not expect that to happen. I am sure that health boards want to improve their reputations. They would not want to run counter to the general direction of public feeling—or Government feeling—on a matter. I am positive that boards will take on board panels' comments.
Mary Scanlon asked about funding of the independent scrutiny panels. I reassure her that we will, of course, fund their work.
I hope that I have responded to some of the key points that were made and the key questions that were asked during the debate, but I return to the principles and process for a moment. We believe that independent scrutiny should, as far as possible, fit with existing board processes in order to avoid delays and extra bureaucracy in implementing necessary change. Richard Simpson made the point that we should avoid extra bureaucracy. The independent scrutiny panel will begin to gather information and evidence and assess options at the option-development stage of change. Because scrutiny will begin early, it should not add significantly to the resources or timescales that will be required to consider and implement service changes.
Feedback from the Scottish health council confirms that, if the public are able to contribute fully to the development of options and are to be satisfied that the full range of viable options is being considered, that is likely to lead to effective involvement and consultation, and trust will be established and maintained.
When health boards propose major changes to valued local services, it is their responsibility to make a clear case for change that is backed up with robust evidence, and to engage effectively with local communities in doing so. There will be cases in which, although public opinion opposes change, there are grounds for making it. As the cabinet secretary said, we will not shirk tough decisions. However, in order to get to that point in a way that builds as much public confidence as possible, we must have a consultation process in which the public have faith. Independent scrutiny is a key component of that.
The Scottish health council will continue to be responsible for quality assuring the public engagement and involvement processes that NHS boards follow.
Will the evidence base that is presented to the independent scrutiny panel include the cost implications of service delivery and the cost pressures that the health board is facing in relation to efficiency savings?
Costs are always part of the evidence that boards put forward. They will be scrutinised in the independent process. Along with clinical evidence, financial information is part of the important evidence that has to be scrutinised.
The Scottish health council does not have any direct responsibility for assessing the information and evidence that will be provided in support of the case for service change. The council has supported the recent examples of independent scrutiny by providing a central secretariat. Feedback suggests that the secretariat role is crucial in providing high-quality administrative support to panels.
In briefly reflecting on the experiences of the first two independent scrutiny panels, we have learned that small panels of independent experts can quickly get to grips with complex NHS service issues and provide informed commentary on board proposals and the evidence that underpins them. We can see the merit in the view that was expressed by many people during the consultation that, in appropriate cases, such focused commentary by a small panel of independent experts will help to provide the public with the relevant information and confidence to engage in meaningful consultation about the choices that are being offered and changes that are being proposed.
The work of the recent panels clearly shows that independent scrutiny can and does work. Our guidance on informing, engaging and consulting the public in developing health and community care services, and the Scottish health council's role in ensuring that boards comply with it, will mean that services are developed with the people, not for the people. That approach will mean that services are changed only for the better.
Today's debate has added to our recent consultation on the future of independent scrutiny, and I thank members for their constructive contributions. We look forward to making an announcement on the process next month.