Health Boards (Membership and Elections) (Scotland) Bill
The next item of business is a debate on motion S3M-3543, in the name of Nicola Sturgeon, on the Health Boards (Membership and Elections) (Scotland) Bill.
I am extremely pleased to open the debate on what I consider to be an extremely important bill. I thank all those who contributed to its development. Many people took the time to become engaged during the consultation and the bill's passage through the Parliament, and I believe that the bill that we have considered—and which I hope we will pass—is significantly better for their involvement.
I especially offer my thanks to the Health and Sport Committee, the Finance Committee and the Subordinate Legislation Committee for their extremely thorough scrutiny of the bill. I also thank the committee clerks, who worked hard to support committee members and enable them not only to scrutinise the bill but to improve it at different stages. I hope that committee members recognise that the Government has, in turn, worked hard to address as many of their concerns and comments as possible. We have made a number of amendments and, although we have not been able to agree on absolutely everything, we have found consensus on most of the contentious issues. I hope that all members agree that we have worked well together to strengthen the bill.
I also take the opportunity to place on record my sincere thanks to my officials in the bill team, who have worked extremely hard on a short but complex bill. Their work has produced a bill that delivers one of the Government's key manifesto commitments in a way that is sensitive to the suggestions, comments and concerns that have been expressed throughout the bill process.
It is important to set the bill firmly in context. Members will recall that, in "Better Health, Better Care: Action Plan", we set out our vision of a mutual national health service, in which ownership and decision making are shared with the public and the staff who work in the service. The bill—together with our proposals to strengthen existing public engagement processes, our plans for a participation standard and ownership report and our intention to introduce a new patients' rights bill—is designed to bring to life the concept of mutuality.
Many people throughout Scotland believe that there is a democratic deficit in the operation of our health boards. Too often, the public have felt shut out of the big decisions that health boards take day and daily that account for significant sums of public money. The bill addresses that democratic deficit.
I believe that democracy is always a good thing and that opening up health boards to the public through elections will deliver better decision making and, ultimately, services that are even better than those that we already enjoy. The bill's clear objective is to allow the public's voice to be heard and, more important, to be listened to at the heart of the decision-making process, which is exactly how it should be.
Understandably, people have strong views, but, more important, they have real-life experiences of what does and does not work in the national health service. People should therefore be involved in considering developments in their area, in decisions about how resources are best spent to meet challenges and in the day-to-day decisions that impact on the health and lives of everybody in Scotland.
Of course, notwithstanding the passing of the bill, health boards will still be faced with regularly making many difficult decisions.
I think that we all recognise that there will always be difficult decisions. In recent years in particular, the impact of health board decisions on, for example, the St Margaret of Scotland hospice—the cabinet secretary knows a lot about that—and the Vale of Leven hospital has meant that the legitimacy and public standing of health boards have deteriorated. Does the cabinet secretary think that elections to health boards will raise expectations about the security of their decisions?
I believe that to be the case, and I agree with Gil Paterson. The position is unfortunate because, despite the fact that difficult decisions must be made and that it is inevitable that sometimes health boards take decisions with which the public disagree, I believe that our health boards do a fantastic job on behalf of the people of Scotland on most occasions and that they deserve the country's respect for that. I believe that the bill that we will—I hope—pass today will enhance not just the public's ability to influence decisions but the standing of health boards in the communities that they serve.
While welcoming the bill, does the cabinet secretary understand the concern of nurses that, under the alternative pilots outlined in her letter of 4 March, there may not be a position for a nurse director? Given how long and hard they fought for that position, can she guarantee that there will continue to be a nurse director on the board under any alternative pilot?
Malcolm Chisholm will be aware that one of the alternative pilots that we have proposed is intended to address what many people think is the imbalance in health boards between executive and non-executive directors. Indeed, members who are in the chamber have made that comment during the bill's passage. One of the pilots will therefore look to limit the number of executive directors who have voting rights on health boards. Having said that, I hear what Malcolm Chisholm says and I agree with him about the importance of nurse directors. I will certainly take very seriously his point. Like other professionals in our health service, nurses make an enormous contribution and it is right that their voice is heard.
Electing people to health boards does not take away the need to make difficult decisions, but, in my view, it ensures that the quality of the decision-making process is enhanced and improved. We know that, when people are involved in that process and understand and become persuaded of the reasons for change, they are far more likely to be drivers of change than barriers to it. However, I have listened at all stages of the bill to the views of those who have urged caution. That is why the elections that the bill will enable will be piloted and independently evaluated before any decision is made on roll-out. It is right that we take that approach and that Parliament, and not just the Government of the day, will decide whether to roll out the proposals across Scotland.
I know that some people are concerned that the flip-side of local democracy could be a postcode lottery of provision. It is precisely to allay that concern that the bill will not change the ministerial powers of direction or the clear line of accountability that exists from health boards, through me, to Parliament.
I hope that members agree that we have responded positively to concerns expressed about the power of ministers to remove directly elected members. Indeed, we supported an amendment to that effect at stage 2.
The bill means that a majority of a board's members must consist of directly elected members and locally elected councillors. For the first time, it gives statutory underpinning to local authority membership of boards, which I believe is extremely important.
The minister should wind up.
If the bill is passed, it will enhance the decision-making process, which will be a good thing for communities right across Scotland.
I move,
That the Parliament agrees that the Health Boards (Membership and Elections) (Scotland) Bill be passed.
Like the cabinet secretary, I would like to thank everyone who has been involved in bringing the bill to this stage. Like her, I know just how hard the bill teams work. Although it might be a relatively small bill, a number of serious issues had to be teased out. I also thank the Health and Sport Committee.
It is, of course, Labour Party policy to support the introduction of pilots for directly elected health boards. I pay particular tribute to Unison Scotland, which has pressed that case through our policy-making processes, and to Bill Butler, Jackie Baillie, Helen Eadie and Richard Simpson, who have worked so hard to refine the bill so that we could reach a position in which we felt that supporting it was the right thing to do.
Having said all that good stuff, there are some cautionary notes that I would like to put on record, which I hope that the cabinet secretary will deal with when she sums up. She will be aware of some of the concerns that exist—particularly those of the Royal College of Nursing—about the situation that Malcolm Chisholm outlined, and I am grateful to her for her comments on the matter.
We were concerned to ensure that genuine alternatives to direct elections as a way of involving the public in meaningful participation would be introduced, and I think that the options that have been brought forward today still require some work. We might have to take some responsibility for that, given that we pressed the cabinet secretary to produce options in advance of stage 3. Option 1 would involve at least one member of each public partnership forum in a health board area being appointed to the health board, but if sufficient support and resources are not available to ensure that the PPFs work properly, simply appointing people from those bodies to health boards will not, in itself, necessarily ensure additional public participation.
The options that the cabinet secretary has developed include enhancement of the public appointments process to increase diversity. We have all struggled with that issue in relation to a range of public appointments over a number of years. I would certainly like more detail to be provided on how that proposal will be implemented and what specific actions will be taken to ensure that there is delivery.
A further point that I want to put on record relates to resources. There was considerable discussion of the cost of introducing the use of personal identifiers for health board elections. If we are to make public participation happen, adequate resources need to be set aside. The detail on that is sketchy. As I said in the stage 1 debate, I am keen to ensure that public participation is not just for the affluent and the articulate but that it stretches out to involve voluntary sector organisations, patient groups and people who live with and have to manage long-term conditions, so that we can ensure that those people have a genuine opportunity to influence the decisions that health boards ultimately make. I hope that the cabinet secretary will be able to deal with that point in her summing up.
A specific public participation issue was brought to my attention fairly recently. Information must be provided to people that is meaningful; it must also be accurate and up to date. A patient who went to their local general practice surgery picked up a leaflet that invited them, with great gusto, to have their say in local health services. It described how to get involved, mentioned the public partnership forums and what they would do, and gave dates for a range of meetings. It was only on investigating the matter further that the person concerned discovered that the meetings that were referred to had taken place almost two years previously. There is little point in having the will to involve the public if that is not filtering down to the ground. If we are preventing people from participating by getting such basic things wrong, we still have a considerable amount of work to do.
Having made those points, I welcome the fact that we have reached this stage. We will support the bill at stage 3, even though members did not agree to all the amendments that we wanted. I hope that the cabinet secretary will continue to work on the points that I have raised. We will do what we can to ensure that the bill actually makes a difference in practice. At the end of the day, there are communities—geographical communities and communities of interest—who feel that their views have not been adequately represented by health boards in the past. That is what has to change, once the bill is implemented.
On behalf of my party, I thank the clerks and the excellent and feisty convener of the Health and Sport Committee, as well as all who have helped in the bill's passage.
It is odd, to say the least, that in the midst of the worst economic recession this country has seen since the 1930s, the democratically elected representatives of this Parliament are passing a bill for elections to health boards, when the full costs of those elections, once they are eventually rolled out, will be taken from front-line services. However, I acknowledge that the costs of the pilot elections will not be taken from front-line services.
Written evidence to the committee did not offer a ringing endorsement. Only 27 per cent of responses were in favour of elections to health boards. Of the 19 responses against the proposal, only five were from national health service bodies. We should not therefore assume that it is the NHS that is against elections.
I hope that Jamie Stone will agree that not all health boards are poor at consulting. However, there is no doubt that the demand for elections comes from health board areas with a history of poor engagement. As I have said before, I have not met an MP or an MSP in the Highlands who has ever been asked to promote elections to health boards.
People in some parts of Scotland will now face eight elections—relating to their national park, the Crofters Commission, their community council, their local authority, the Scottish Parliament, Westminster, the European Parliament, and now their health board. However, we will support this bill to have pilot elections. It could be said that we belong to the sceptical side, but we will carefully consider the outcomes of the pilots and the extension of the franchise.
I have some concerns. I am trying to understand clearly in my mind what criteria will be used, in the evaluation process, to judge success or failure. Some people may think, because decisions went their way, that the pilot was successful; but others may think, because decisions did not go their way, that the pilot was a failure. We have not debated the evaluation process, which is for another day, but I am pleased that the cabinet secretary agreed to the use of the super-affirmative procedure. When we come to roll-out, parliamentarians will have to receive substantial information that spells out exactly why the elections proved beneficial for patient care.
The SNP naturally wants to keep to its manifesto pledge, but the cost to the NHS—taken from front-line services in the depth of today's economic recession—has to be a significant consideration as it will have a serious impact.
One and the same consultation—or one and the same chance to participate, work in partnership, or form procedures for joint decision making—can lead to huge support and enormous criticism, sometimes depending on the outcome of decisions. I hope that the health boards used in the pilots will not avoid controversial decisions during the pilots; rather, I hope that they will take on the difficult decisions faced by the NHS today.
Change is needed in the NHS, to embrace new technology and new ways of working and to empower patients to take more responsibility for the management of their own care—a point that Cathy Jamieson raised. Sometimes, very difficult decisions must be made, and the challenge for elected members will be to face those tough choices to ensure that Scotland has an NHS that is fit for this century and fit for the patients who depend on it.
It is fair to say that the proposition that directly elected health boards per se were going to address all the problems of NHS boards was one that underwhelmed my party by quite some way. Indeed, in looking at the bill in the first instance, we thought it curious because it was a bit of a hybrid. Section 1 purported that the bill would give effect to directly elected health boards. However, when one read sections 2 to 6, one found that what was really intended was simply to proceed with pilots to that purpose. I am pleased that the bill is now fundamentally different from the one that was introduced.
The bill is fundamentally different now because its long title—which, after all, sets the principles on which it is to be considered—makes clear that it is a bill to provide for pilots that might, after Parliament has given due and careful consideration to their results, lead to some other form of board. Also, as Mary Scanlon said, the serious changes that have been made to section 7, providing for the use of the super-affirmative procedure for roll-out orders, mean that the bill will allow the pilots to take place while making it clear that Parliament alone will decide which pilot might be rolled out.
As I have listened to the debate on the bill, in which I have taken a keen interest, one of my main difficulties has been with the bill's starting point. The cabinet secretary and I exchanged views on the matter in discussing the committee's report, but Bill Butler will be gratified to know that I will follow his example and resist the temptation to quote myself. I do not believe that direct elections will necessarily be the answer. The evidence shows that there is a completely mixed picture across Scotland. As Mary Scanlon points out, boards such as NHS Highland appear to have a higher level of engagement, whereas in some board areas the engagement is, frankly, downright awful—in fact, unacceptable. There is no doubt that the situation has resulted in great cynicism.
However, when one hears how the boards operate, what the balance is between executive and non-executive directors, what they believe to be their functions and how they act as a matter of corporate governance, one is left with a horribly confused picture. I became worried that if what is supposed to be the solution is simply bolted on to that confused picture, it may not work. Therefore, I repeat what I said in the debate at the committee stage: it would be helpful, even before we get to the stage of considering the pilots, to clarify the precise nature of the boards and the way in which they are supposed to function.
My view is supported by the cabinet secretary's letter, which sets out the kind of pilots that she would contemplate. I share Cathy Jamieson's view that those of us who posited the idea of pilots have a duty towards them, and I note with considerable interest that the cabinet secretary intends to involve stakeholders, active partners and the Health and Sport Committee. That will be helpful, as I recognise that we have a duty to contribute to that process.
A reason is given for the suggestion to reduce the number of executive members of a health board, but it is not based on any careful analysis of how the boards function at present. Nor does it follow that, apart from by increasing the ease with which a non-executive majority can be created, reducing the number of executive directors will address the issue of why, at present and with the current numbers, boards do not always function. That remains a fundamental issue, which is why some of us may wish to suggest different forms of board.
The Lib Dems have made our opinion clear throughout the passage of the bill that there is merit in an experiment in which local councillors have a greater degree of influence than they currently exercise.
I acknowledge the cabinet secretary's role in the constructive work to change the bill fundamentally to recognise that it is there to create the circumstances in which pilots can take place. It means that the bill is now an instrument that the Liberal Democrats are prepared to support. That is how we will vote this evening.
I acknowledge the hard work that Bill Butler put into the bill, which began long before I became an MSP. I hope that he achieves a sense of satisfaction at seeing his efforts come to fruition today. I acknowledge, too, the work that has been put in by my colleagues on the Health and Sport Committee. Together with the cabinet secretary, we have arrived at a bill that is a lot more satisfactory than it might have been.
The core difference between the health services of England and Scotland is that, in England, the public are largely seen as consumers of health services, while we, more in the tradition of Aneurin Bevan, founder of the national health service, see the public also as owners. The difference is more than academic. Owners of a venture have responsibilities not only for the quality of the service that is provided but for how the venture is run, its direction, its funding, how it treats its staff and a variety of other factors that are of much less concern to a simple consumer.
To develop that theme, Governments in Scotland—particularly this one—have placed great emphasis on public ownership, whereas Governments in England have elected for choice and a much greater private involvement in the provision of services.
The problem is that up until now, those responsibilities of ownership in Scotland have not been accompanied by a mechanism whereby they can be easily discharged. The health minister of the day appoints members to health boards and those members decide collectively how the health service is run in their area of responsibility. Few members of the public know even the names of the non-executive health board members purportedly looking after their interests. They often come from a small section of middle-class society and are not easily accessible. The bill seeks to ensure that, in future, they are chosen by the voters in their area and are responsible for explaining to those voters any decisions that they make.
What are the alternatives that some say are more desirable? Various bodies are associated with representing the public voice in the health service. There are the illness-based organisations, which are organised and effective but which—very reasonably—are only interested in advocating their particular causes. Public partnership forums relate only to community health partnerships and not to hospital services, and are nearly all groupings of self-selected individuals, which can be dissolved at will by a health board. Independent scrutiny panels are great for considering specific issues but not for considering the entire direction of a service. The Scottish health council works largely through the efforts of self-selected volunteers. None of those bodies brings members of the public anywhere near the centre of local decision making, and all but independent scrutiny panels can easily be ignored.
It is perhaps not surprising that the most vituperative opposition to direct elections comes from those whose somewhat cosy world would be disturbed by them: existing health boards and professional organisations. They argue that directly elected members will not be representative of the community that they seek to represent. Do they really think that that representation is achieved at present by the non-executive directors who are on most health boards? They support investigating how the existing range of mechanisms can be improved to achieve greater public engagement in decision making, but those are meaningless words if existing mechanisms cannot possibly be adapted for that purpose. That is why I have doubts about the likelihood of success of the three alternative pilots that we have before us. I do not see how, at the end of the day, any of them can meaningfully involve the wider public in the decisions that affect them so much. We need the public to be at the centre of decision making, not at the fringe.
I began by highlighting the role of the public in Scotland as owners of the health service. Owners of anything often have to make difficult decisions, for example where to invest and how much. For too long, politicians from all sides have tended to treat the public more as children than as adults in that respect. In the past, we have too often said, "We can have the best health service in the world, free at the point of need, and not have to pay for it." Now is the time to realise that we are dealing with responsible, sensible adults. They must be directly involved in spending decisions, rationing decisions and all the awkward but essential aspects of delivering an effective health service in the modern era.
Directly elected members of health boards will be visible, accessible and accountable to—and ultimately replaceable by—the public. I see no more effective way of running a responsive public service.
First, I congratulate the Cabinet Secretary for Health and Wellbeing on introducing the bill. I am sorry only that she failed to accept my amendment, which would have ensured that a simple majority of 50 per cent of health board members plus one would have been directly elected by the public in health board elections. I never thought that I would see the day that Ms Sturgeon would be described as timid and conservative and I hope that it is simply an aberration.
However, I am a democrat. The Parliament's will, as expressed earlier this afternoon, has been to reject Labour's radical policy position and to opt for the Scottish National Party Government's overly cautious position. Nevertheless, on the basis that half a loaf is better than none, the Labour Party will, as Cathy Jamieson has indicated, support the bill at decision time. It is still a significant reform that I hope can be built on in the years ahead. Finally, I applaud the work of the members of the Health and Sport Committee and its excellent convener, Christine Grahame.
I have believed for some time that there is strong support in Scottish society for the introduction of direct elections to Scotland's NHS boards, I believe that there is a compelling case for greater democracy, accountability and transparency in decision-making processes for local health services, and I continue to believe that the introduction of direct public elections is the best way of achieving greater accountability and transparency.
The bill will significantly increase public involvement in local NHS services by involving people in the planning and delivery of health care services in their own communities. I emphasise that, in supporting its main aim of introducing more democracy into the operation of health boards, I am not saying that all health board decisions are necessarily wrong or detrimental to local health services. Such a view is simply absurd and I agree with members who have made the same point.
However, there is an undeniable problem with the operation of health boards and the way in which decisions are reached. The public perception is that such decisions are flawed. Indeed, the anger that some people feel about certain decisions is to an extent generated by the manner in which they are made. They are made in secret and are seen as being predetermined, with little or no explanation as to how they have been arrived at. They often ignore the community's views and the responses that have been made in the board's own consultation process.
Many people believe that health board consultations are, in effect, fake. That is not a happy situation; such a view corrodes confidence in socialised medicine and in our NHS. That is simply not acceptable.
As members know, there is no perfect method for consulting the public on major local health issues and I do not believe for a moment that direct public elections will lead to everyone being happy with every decision that is made by an NHS board. This policy is not a panacea. However, I contend that decisions that are made by health boards on which there is a large element of democratically elected members will have more credibility than decisions that are made under the current system.
Introducing greater democracy will mean more than just structural change. This kind of electoral accountability will involve patients and communities and will provide an opportunity for public debate and greater access to information. That is, of course, a good thing.
I believe that the bill will, as Unison correctly pointed out in its evidence to the committee, lead to a sea change in the culture of NHS boards. I believe that that will be a very good thing. We have all had enough of top-down bureaucratic decision making, which too often merely echoes vested interests. That is a bad thing.
There has been a fairly long journey to arrive at this juncture for some of us. Despite the reservations that I have expressed, I genuinely think that the bill is a welcome first step towards the positive extension of democracy and democratic accountability in our NHS. On that basis, Labour will support the motion at 5 o'clock. I welcome the Government's endeavours on the matter and support the motion.
It is appropriate to say a few words of thanks at this point. I thank my colleagues on the Subordinate Legislation Committee, two of whom are in the chamber, and the clerks to that committee. I should not forget the legal team, who backed us up at all times with detailed and expert advice. Without those people helping us, we would not have done as much as we managed to do. Like others, I thank the Cabinet Secretary for Health and Wellbeing and her team and the bill team for their thoughtful and effective responses to the Subordinate Legislation Committee's comments.
It is clear that the issue of personal identifiers has divided members. The cabinet secretary made the point that what was proposed would delay things.
I acknowledge the work that Helen Eadie put in on the Subordinate Legislation Committee on the powers of ministers to dismiss elected members. I sought not to have a division in the committee on that because, apart from its role of considering the commas in and language and appropriateness of instruments, the Subordinate Legislation Committee has a role as the Parliament's guardian in taking a view on which procedure should be used for an instrument. There are members of many parties in the Parliament, and it is helpful if the Subordinate Legislation Committee tries to speak with one voice as much as it can, as it has a role in representing the whole Parliament. However, we knew perfectly well when we took a decision on the powers of ministers to dismiss elected members that Helen Eadie would press her point in the way that she has done. So that my true colours as the convener of the Subordinate Legislation Committee can be known, I should say that I voted for Helen Eadie's proposal. However, like Bill Butler, I accept the democratic will of the Parliament.
I recognise, as my colleague Ross Finnie does, the work that has been done on extending the franchise and recording the names of 16 and 17-year-olds, and the significant moves that have been made in the right direction on that. I also compliment the cabinet secretary and her team on the speed with which they reacted to the points that we made in the Subordinate Legislation Committee on the roll-out order in particular. I recognise that the Parliament's interests have been safeguarded, and thank her very much for that.
The cabinet secretary talked about addressing the democratic deficit and enshrining local councillors in and protecting them on health boards. To conclude my brief speech, I want to take up a point that Mary Scanlon made about the varying levels of accountability in health boards. There is no doubt that there was a perceived democratic deficit some time ago with respect to Highland NHS Board, which covers the areas that Mary Scanlon and I represent. It did not enjoy the support of ordinary people in the Highlands. Part of the perceived deficit was due to what might be referred to as a geographic bias. People in my constituency and in more far-flung parts of the Highlands said that everything was controlled in Inverness, which was why we reached the impasse that we did on issues such as maternity services in the far north of Scotland. The bill will, of course, help to address that issue, because there will now be elected representatives.
It is probably not surprising that the other major concerns existed in Fort William, Ardnamurchan and Lochaber, where 22 per cent of the local population turned up to a public meeting on the health service. I think that Jamie Stone would agree that there was a good outcome for both of those excellent campaigns.
I completely accept Mary Scanlon's point. People power was exercised in a way that was encouraging to all members. We all believe in democracy.
I come to my final point. Can the issue of geographic bias be remembered in view of the powers that remain to the cabinet secretary and ministers to appoint members of health boards? It would be a huge mistake for us to say that, simply because there are elected members in Highland, ministers need not worry about geographical coverage and may appoint only members who live in or around Inverness—the issue will still have power and weight.
As Ross Finnie said, we Liberal Democrats see the bill as a step in the right direction. We recognise that the democratic voice of the Parliament has spoken and will support the bill shortly.
I offer just a few words in closing for the Conservatives. I congratulate all those who have contributed to the considerable work that was involved in taking the bill through the Parliament. Both Mary Scanlon and I pay tribute to Bill Butler for the passion that he has brought to the subject. I do not share his passion for every subject that he brings to the chamber, but he has led on this matter for a number of years. Not all parties approach the bill from the same perspective or with the same enthusiasm, but all have acted constructively to develop a final measure that commands support across the chamber. I thank and congratulate the cabinet secretary and the minister for the flexibility that they have shown throughout.
The purpose of the pilots is to test the policy. As representatives of a party that supports the principle of directly elected members serving on health boards—although, on the basis of the discussions that have taken place, we are slightly more sceptical about the issue than we once were—we will support the bill in a few minutes' time.
It is important to note that the revised financial memorandum assumes that as much as 20 per cent of the electorate may be affected by the pilots. It is fair to suggest that such widespread coverage goes beyond what many members of the public assume to be the scope and reach of a pilot. For that reason, it is not enough to be glib about dealing later with general concerns that arise in relation to the pilots. A huge and committed effort will be required by all those who are involved in the pilots to ensure that, as a consequence, local health care is not compromised, but enhanced through greater transparency and accountability.
We must all wish the pilot areas every success. It will be unfortunate if the pilots fail, because one must assume that any judgment of failure will be made on the back of a collapse of public confidence, arising from situations too diverse to predict. Mindful of that point, I believe that ministers will have to be even more closely involved in the affairs of the pilot health boards than in those of boards elsewhere—not necessarily to interfere, but to satisfy themselves that the core business of the boards remains on course.
We have always argued that success will depend, in part, on those elected being supported sufficiently to enable them to make meaningful contributions and to have the courage of their convictions in any crunch vote; they must never be left feeling beleaguered or overwhelmed. However, we can all allow ourselves to be just a little excited at the prospects offered by the pilots, in the hope that the public will come to feel engaged in the process. As the bill is a health measure, it is appropriate for me to conclude by saying that the proof of this pudding will be in the eating; we must all hope that it will sit easily in our stomachs. With that cheery thought, we wish the pilots well.
I join other members in thanking the cabinet secretary and the bill team for working flexibly with the Health and Sport Committee. I thank colleagues on the committee and all those who have given evidence on the bill for their work.
The Parliament can be proud of the fact that it has moved quite a long way since it was established in 1999. When we first gathered to look at the state of the NHS, the available guidance on how the public was to be consulted on health service issues was, to say the least, antiquated. As Ian McKee said, it reflected a situation in which the NHS was often autocratic and paternalistic. In the past 20 years or so, we have moved to a situation of far greater partnership in the delivery of health care. It is therefore entirely appropriate that the public should have a sense of ownership of how services are delivered at an operational and strategic level. The bill will help to deliver that.
Ross Finnie, Mary Scanlon and others have made the point that, in the period between 1999 and the introduction of the bill, a number of changes have substantially altered the process and have resulted in different health boards progressing at different rates. When considering the proposal for elected health boards, we should not allow that progress to be lost. Those boards that have moved are now involved in a process of genuine consultation, using public forums, citizens juries and a range of other mechanisms that have been introduced.
As many members have said, that does not remove the problem of making hard decisions when communities are divided. I remember the discussions on where the new hospital in the Forth Valley NHS Board area would be placed. Falkirk wanted it in Falkirk, Stirling wanted it in Stirling and, as I represented mainly the Clackmannan area, I did not care as long as we got a bridge that gave us rapid access to it. I ended up being the meat in the sandwich between the two groups, but a decision had to be made. There was wide consultation and a decision was reached that was accepted.
There were people around in 1999 whose view of consultation was, "This is the option that we have decided on, which is what you will accept, and we will now consult." That is not consultation. Unfortunately, some health boards still have a culture problem in that respect, which will not be totally solved by the pilots.
Some may see the pilots as overly cautious; they may ask why we did not move to direct elections for all health boards. I sensed, from their final speeches, an unusual partnership developing between Dr McKee and Bill Butler. Had Dr McKee been in the Parliament in the previous session, there might have been a different configuration of support for Bill Butler's proposal for directly elected health boards as a totality.
It is important that the evaluation of the pilots is robust, and the Parliament's decisions today have reflected that. With due respect to our Conservative colleagues, it is not only about the economic climate, although that is important. The evaluation must be robust and must demonstrate that the elections add value to the process of ensuring democratic accountability, as well as a sense of ownership. It must also demonstrate that elections do not undermine the existing structures of participation, but add to them, and it must commence well before the elections so that the baselines of existing participation and consultation processes can be fully established.
The super-affirmative resolution, which will be accepted at decision time and was accepted in an amendment to the bill, has been an important element of the bill as it has emerged.
In 1948 we gained a new institution, which no party would now try to remove, but in doing so we lost one thing: local community control. Until that point, health services were local rather than national. When the Parliament votes at decision time, it will re-establish a degree of local control, which is important.
I support Ross Finnie's view—I hope that the cabinet secretary will work with us on the matter—that the involvement of a substantial number of councillors, not only at the level of community health partnerships but on the health board, should be one of the alternative pilots. That would test a more economic version of representation, albeit indirect, and it would allow us to come back at the time of the super-affirmative resolution, if that occurs, and find out what the best method is for ensuring the democratic accountability that the whole of the Parliament wants.
I thank all the members who have contributed to the debate; it is usually not fair to single out one, but for the purposes of this summation I will single out Bill Butler. He has doggedly pursued the issue and he deserves considerable credit for that. I am glad to see—I hope that it is not for the last time—that in the cause of progressive reform he has found the SNP Government to be perhaps a more willing partner than the previous Administration.
Will the cabinet secretary take an intervention on that point?
I know that I should not, but I will.
I hope that this will not be the only time that the SNP brings something to the chamber that can be seen as progressive and radical.
I will move swiftly on.
I will quickly address some of the points that have been made in the debate.
Cathy Jamieson said, rightly, that some further work is needed on our suggestions for alternative pilots. I acknowledged that in the letter that I sent to Opposition spokespersons. I said that the details will be worked out in parallel with our preparations for elections and I offered to include not just the Health and Sport Committee but the Opposition parties in those further discussions. I hope that they will all take me up on that offer.
I thank Mary Scanlon and her colleagues for their constructive approach to the bill. It is fair to say that Mary Scanlon is, if not the biggest sceptic, one of the biggest sceptics in the Parliament about elected health boards. I hope that the pilot elections will help to persuade her of the case for them. It is to her credit that she has not allowed her scepticism to lead her to try to block the pilot elections and deny other people the right to participate. In her speech, she offered the view that there are too many elections in Scotland. Notwithstanding my earlier comment that democracy is always a good thing, I tend to agree, and that is why I will be only too happy to see the Westminster elections rendered redundant when Scotland becomes an independent country. We will be glad to be of service in that respect.
Ross Finnie said that elected health boards are not a panacea. I agree. Electing people directly to health boards can help to bridge the democratic gap that undoubtedly exists in the minds of many people—and in reality in many communities—throughout Scotland, but such elections will not in themselves deal with some of the culture issues that Richard Simpson mentioned. Dealing with those issues is part of a much bigger effort to ensure that the health service reflects the communities that it serves and listens to the views that are expressed. However, the elections will be a significant step in that direction.
In saying that, and given her remaining powers of appointment, is the cabinet secretary mindful of the point that I made about the geographic bias in a health board area as big as that of NHS Highland?
I am always mindful of the points that Jamie Stone makes, and that one is no exception. The pilot elections will test such concerns.
If the bill is passed today—I am glad to say that it looks as if it will be—the intention is to pilot the elections in two health board areas that are representative of Scotland's population and geographical diversity. The pilots will take place over a reasonable period. I hope to announce the decision on which boards will take part in the pilots before the Parliament goes into the summer recess.
I conclude by doing something that I did not do earlier this afternoon, and that is quoting Bill Butler. There is no doubt that the bill that we are about to pass represents a "significant reform". As I said earlier, I believe that it is a significant progressive reform. It will undoubtedly result in a real change in the make-up of health boards and a shift in the balance of power in health boards. That is the intention of the bill, and rightly so. It will ensure that there is locally mandated representation on health boards while, crucially, retaining the strength of many of those who currently sit around the table.
Direct elections represent a significant step towards ensuring that the public voice is heard loudly and listened to at the heart of NHS decision making. I agree with Jackson Carlaw that that is an exciting prospect. As Ian McKee rightly said, the bill that we are about to pass begins to bring to life the concepts of mutuality and public ownership. I am delighted that there is a further benefit to the bill. In addition to the benefits for the running of the health service and ultimately for the quality of care that patients receive, it will allow 16 and 17-year-olds to participate in elections for the first time in the UK. That is a great step forward, and I hope that it is only the first step on the road to allowing 16 and 17-year-olds to vote in all elections.
I thank all members for their contributions. I hope that the Parliament votes unanimously to pass the bill. I believe that communities throughout Scotland will be grateful to us for doing so.
That was a noble effort, cabinet secretary, but I have no choice other than to suspend the meeting for 30 seconds.
Meeting suspended.
On resuming—