Making the National Health Service Local
The next item of business is a debate on motion S2M-5572, in the name of Andy Kerr, on making the NHS local.
The national framework for service change and "Delivering for Health" set out the rationale for a fundamental shift in the balance of care. Simply put, our goal for the health service in Scotland is that it should be
"as local as possible, and as specialised as necessary."
As society changes, we need to move away from the traditional models of reactive and episodic care in the acute sector. We need to pioneer and embrace preventive, integrated and continuous care that is delivered in local communities. By expanding and developing local services, we will make the greatest improvement in the lives of the people of Scotland.
I will highlight the progress that has been made to shift the balance of care in the past few years. Primary and community care premises that are fit for purpose are key to the delivery of high-quality care. We have made significant progress on addressing the years of neglect in the 1980s and 1990s. More than £138 million has been committed to 165 projects since 1999, in addition to the investment that NHS boards have made directly.
Examples of what has been achieved include the Leith community treatment centre, the north-west Kilmarnock partnership centre, the Easterhouse health centre, the Aberdeen dental institute and other dentistry facilities throughout Scotland. The first hospitals of a new generation of community hospitals have opened in Hawick, Easter Ross and mid-Argyll and more are to follow in Clackmannan, St Andrews, Girvan and Midlothian.
The recently published community hospitals strategy underlines the fact that NHS boards should provide a range of day-case surgery, minor injuries and diagnostic services in those revitalised local facilities. NHS Grampian is one board that plans a radical shift in the location of services so that, by 2010, 40 per cent of overall out-patient activity and 25 per cent of in-patient activity that specialist hospitals undertake will be managed in alternative settings that are closer to people's homes.
The creation of a network of community casualty units throughout Scotland will mean more local access for the vast majority of cases that are currently seen in accident and emergency departments. That will ensure that patients who require more specialist care receive it within the target time in appropriately staffed and resourced emergency centres. That approach adheres to the principle—which the Parliament overwhelmingly supports—that care should be
"as local as possible, and as specialised as necessary."
However, the significant investment in such facilities is only one part of the step change in NHS Scotland. In the past three years, funding for primary medical services has increased by 50 per cent. The way in which we work with and reward our general practitioners focuses on Scottish health priorities and ensures the provision of high-quality care and chronic disease management in the community.
In 2005-06, at least 95 per cent of practices achieved targets for important indicators such as the control of blood sugar, blood pressure and cholesterol levels in patients with diabetes. That approach prevents the worsening of health problems and fundamentally improves the patient's health and quality of life. In addition, it reduces the risk of hospital admission.
Our goals are therefore to shift services from hospitals to the community and to shift the nature of services from reactive and episodic care to preventive and continuous care.
The minister will be aware of the approach that NHS Highland has taken to the proposed closure of Glencoe hospital. Does he agree that, in general, any such proposal should be attached to a detailed and robust plan that sets out clearly the alternatives that are to be put in place? Does he agree that communities require such a detailed plan, in which the long-term arrangements for care of the elderly in particular are provided for, before it is reasonable to expect an application to close an existing hospital to be considered properly?
I share that view. It is incumbent on all health boards throughout Scotland to ensure that, before significant service change takes place, they provide evidence of alternatives in the community that seek to provide a service that is better, more sustainable and closer to home, which is what many patients in Scotland would prefer.
That brings me to the question of how we view patients. The traditional concept of people as passive recipients of health care, as we do what we need to do to them, is the way of the old health service. We want people to recognise that they should be full partners in their health care. That should apply to their carers and families, too.
We have some good examples of that. In collaboration with Asthma UK and NHS Quality Improvement Scotland, we have been involved in a project to improve the health and well-being of people with asthma through providing and promoting the use of personal asthma action plans. The approach is targeted at children and adults and informs health professionals and members of the public of the benefits of using the plans. The project will increase the support for self-care for people with asthma, anticipate their needs and provide them with earlier care to prevent deterioration of health, thereby reducing the number of emergency admissions.
Improving health and reducing health inequalities are central to our strategy in "Delivering for Health". A range of health improvement services and programmes that are designed to change behaviours and to increase life expectancy and quality of life are reaching out to people in their local communities at every stage of their lives. Antenatal services are providing a fully integrated package of care, ensuring the best chance for a healthy pregnancy and a healthy start to life for all children. Nurseries and schools are becoming health-promoting environments. We have appointed 600 active schools co-ordinators and we are providing free fruit and drinking water in primary schools.
We are also taking our children's oral health action plan into communities through supervised tooth-brushing initiatives and the provision of oral health packs in nurseries and primary schools. That action is already having significant results. Recent statistics show that 54 per cent of children in primary 1 now have no signs of tooth decay. The figures are the best since the programme began in 1987 and show that the Executive is well on the way to meeting its target of 60 per cent of children having no signs of dental disease by 2010.
I appreciate the fact that there have been improvements in dental health, but there are also stark inequalities. That is especially evident in the differences between Cumbernauld and Airdrie—two areas that share the same health board, NHS Lanarkshire. What specific strategies is the minister going to put in place to deal with those inequalities?
The child smile initiative for oral health and hygiene has been established in parts of Lanarkshire and is targeted at those communities. I will come to that in a minute.
I was describing a journey through antenatal care, care of the young person and primary school. Hungry for success has revolutionised school meals and is now implemented in all 2,700 schools in Scotland. For secondary schools, the Schools (Health Promotion and Nutrition) (Scotland) Bill will take the initiative further, with specified nutritional standards for food and drink in all schools and additional standards for physical activity.
In the workplace, the centre for healthy working lives is driving the delivery of the workplace health and well-being agenda. Initiatives such as pathways to health mean that more than 20,000 people are participating in led walks every week, the vast majority of whom are over 60 years of age.
At every stage of human life in Scotland, we are working with individuals and communities to ensure well-being and better outcomes. Those are just a few examples of the many initiatives that exist.
Will the minister take an intervention?
I need to make progress, but if I have time I will take an intervention from Mr Stevenson later.
Delivering for health commits us to strengthening primary care services and to providing anticipatory care in the most deprived communities in Scotland. That has led to keep well—a new and ambitious approach that is aimed at engaging people who have not traditionally made full use of our national health service, especially those with the greatest health needs. We have identified the most challenged and deprived areas, and the first keep well services are now operating in community health partnerships in Greater Glasgow, Lothian, Tayside and North Lanarkshire.
Services in those areas are being tailored to meet the needs of the communities. In Airdrie, keep well screening is being offered in the evenings in the local community centre and library to maximise uptake. Many of those who are traditionally the most reluctant to come to the national health service are now being driven into it and are being offered screening and appropriate interventions. I am pleased with the early figures that I have for the initiative. Since October, a total of 2,082 people have attended keep well health checks in Lanarkshire, and there have been a total of 1,193 onward referrals to weight management, exercise, alcohol, smoking cessation and chronic disease management services. That is where the preventive anticipatory health care agenda rests.
The minister made two brief references to dental care. If someone is told at their dental check that work requires to be done, what is the appropriate maximum wait before that work commences?
Depending, of course, on the specialty and other issues involved, I would hope that the waiting time would fit with our overall targets, which have brought waiting times in the health service down to an historic low. Depending on the circumstances, the waiting time should fit with those overall targets for health services.
Real and decisive action is being taken to address significant health inequalities and challenges. We are committed to ensuring that those who are in greatest need continue to receive targeted and appropriate support. I am therefore delighted to be able to announce that a further wave of keep well services, representing an investment of £10 million during the next two years, will become operational later this year.
Services like those that I have described will be developed in Fife, North and East Ayrshire, Aberdeen, south Glasgow, Inverclyde and West Dunbartonshire. Enhanced services will mean that there will be more direct and targeted interventions than ever before. These are world-leading services that are targeted at those who have the highest risk factors. They will aim to offer appointments in the evenings and at weekends to ensure that there are no barriers to access, and to have outreach workers who will contact patients by phone and by other means to get them into our national health service. The services will benefit from new guidelines for the NHS in Scotland on the prevention of coronary heart disease, which for the first time will consider deprivation as a risk factor when determining treatment. Keep well will be nationally evaluated, and what is learned will be disseminated so that practice can be extended to ensure that we tackle ill health in all parts of Scotland.
Will the minister take an intervention?
I am sorry; I cannot because I am in the final few moments of my speech.
We can see a real shift in the balance of care. The health service is changing the way it works and is making a real difference, saving and enriching lives and, of course, keeping families together for longer.
I move,
That the Parliament supports the goal of further shifting the balance of care away from reactive, episodic care in the acute sector towards preventive, integrated and continuous care embedded in local communities; congratulates NHS Scotland on the significant progress in making its service more local, as required by "Delivering for Health"; welcomes for instance the 50% increase in funding for primary medical services over the period from 2002-03 to 2006-07 and unprecedented investment in primary and community care premises; supports the new community hospital strategy with its focus on providing local facilities and services appropriate to modern-day demands; welcomes the establishment of the Scottish Centre for Telehealth in Grampian and the approaches it will bring to widening access to specialist services, such as seen in the tele-neurology service in Orkney; commends the shift from hospital-based provision to local access for services such as chemotherapy and dialysis and expects community health partnerships to continue to accelerate such a shift; recognises the benefits to communities of more local access for the majority of their unscheduled care needs that will be brought about by the development of community casualty units; welcomes the continuing development of new staff roles and expertise as a means to carry services closer to patients; supports the community pharmacy minor ailments service as an excellent example of improved local access; supports the Scottish Executive's intention to improve Scotland's health, focussing especially on reducing inequalities between those with the best and worst health; acknowledges the contribution to improving health of services in local communities for people of all ages, from improving children's dental health in Glasgow to promoting walking for health by older people; applauds the world-leading anticipatory care "Keep well" services which tackle coronary heart disease in the most deprived communities, and welcomes this package of service change and the continued development of local community health partnerships as a strong and coherent response to the changing pattern of demand that NHS Scotland will face.
I congratulate the Minister for Health and Community Care on lodging possibly the longest motion in the history of this Parliament. We decided to match it with probably the longest amendment in the history of this Parliament.
In the spirit of co-operation, we agree with much in the motion and support the local service developments that are highlighted in the Executive's motion. The Scottish National Party's amendment highlights them, too. Initiatives such as the keep well service should be given our full backing and I am pleased that Dundee has been one of the first areas to benefit. We support such preventive health care measures to tackle health inequalities, particularly in light of the United Nations Children's Fund report, which was published today and shows that the United Kingdom is bottom of the league of 21 industrialised countries for child well-being. The gap between the life expectancies of rich and poor has widened, which is unacceptable for an energy-rich and wealthy nation such as Scotland in the 21st century.
We support the principle of reaching those whose health is in danger, even though they might not yet be aware of it. Men in the 10 per cent least deprived areas expect to live for 13 years longer than men in the 10 per cent most deprived areas. We have some way to go, and we compare very poorly with Norway, which has been top of the rankings for six years now. That is why a Scottish National Party Government will tackle head-on the prevention of major diseases, ill health and low life expectancy rates through our proposals to extend the provision of primary care services in the most deprived communities. We want to focus our attention on intervention in the early years and to identify and work with children who are in danger of developing ill health in childhood that will lead to a reduced life expectancy in adulthood. Our society faces a major challenge in the increase in childhood obesity and its consequent health problems.
Does the member agree that breastfeeding is of major importance and that we need to focus on it more and consider the funding it attracts so that we can help and support the staff and the mothers, and that we should recognise the new research that was published today that underpins the breast is best message?
I certainly concur with that. The breast is best message is an important element of the many initiatives that need to be targeted at communities. I know that the matter is a major issue in Elaine Smith's constituency.
One of our proposals is to double the number of school nurses to deliver school-based health checks and individual health plans. The nurses would work with parents, teachers and local health professionals to prevent bad habits from being established in many of our children who, in adulthood, may be most vulnerable to ill health and premature death.
We have some concerns about the proposed changes to the new community nursing model. The proposals could be counterproductive if they diminish, rather than enhance, the health improvement role of nurses. I have written to the Minister for Health and Community Care about that and we will watch developments closely.
Where we differ from the Executive is that we do not agree that we must have Hobson's choice, as if good preventive health initiatives have to come at the expense of the retention of core acute services that are delivered as locally as possible. We do not subscribe to that assertion. Given that the health budget is now reaching £10 billion, we do not believe that the public need to make that choice.
I am confused by the term "Hobson's choice". It suggests that finance was the key driver for the changes, whereas the changes were driven by clinical evidence in the health boards concerned. That is evidenced by the investment that Lanarkshire NHS Board and Ayrshire and Arran NHS Board have made.
I am pleased to hear that finance is not the issue. In that case, the driver is policy. On this side of the chamber, we believe that both policies are important: people deserve to have core acute services that are delivered as locally as possible at the same time as they are offered the preventive health measures that are being developed.
Is that another spending commitment from the SNP?
The member asks whether that is a spending commitment, but the minister has just said that finance is not the issue. We are pleased to hear that the changes are being driven not by finance but by policy developments.
Will the member give way?
No; let me develop this point.
Of course, many Labour members agree with us that the Kerr report—the report from Professor David Kerr—backs the retention of core acute services, such as accident and emergency and maternity services. They have made that point in the chamber and elsewhere.
Will the member take an intervention?
No, I need to make progress.
As we have said consistently since our submission to the Kerr review more than two years ago, the SNP considers that A and E and maternity services must be delivered as locally as possible. We see merit in community casualty units not as an alternative to A and E units but as a supplement that can take pressure off overstretched A and E services such as those that we have seen closed over the past few weeks.
The medical profession has told us that it cannot support the accident and emergency units that Scotland has at the moment. As the minister said, the issue is not money but the fact that the medical profession has said that it cannot support the existing number of A and E units. Is the SNP's position that no accident and emergency centres should close, despite what the medical profession has said?
We are saying that the proposals to close the A and E units in Monklands hospital and Ayr hospital are fundamentally flawed. For example, the Monklands closure was based on a private finance initiative decision rather than on a clinical decision. If Mr Rumbles speaks to the clinicians in the local area, he will find that they had alternative proposals but that they were never heard because the health board had already made its decision. We need an honest debate rather than a debate that is skewed from the start for other, non-clinical, reasons.
Let me be absolutely clear: as well as promoting the important initiatives that aim to tackle health inequalities, we believe that we need to tackle deprivation, which is the root cause of the majority of ill health and low life expectancy in Scotland. It is time for Scotland to enjoy the same wealth and living standards as other small independent nations such as Ireland, Norway and Finland, which came in the top half of the UNICEF league.
I have pleasure in moving amendment S2M-5572.2, to leave out from "the goal of" to end and insert:
"the delivery of core acute services, such as accident and emergency and maternity services, as locally as possible while also recognising that some specialist services may need to be delivered in larger centres; recognises that "Delivering for Health" provides an opportunity to reverse the trend of further centralisation and keep services local; welcomes the additional investment in primary medical services; supports the new community hospital strategy with its focus on providing local facilities and services appropriate to modern-day demands; welcomes the establishment of the Scottish Centre for Telehealth in Grampian and the approaches it will bring to widening access to specialist services, such as seen in the tele-neurology service in Orkney; commends the shift from hospital-based provision to local access for services such as chemotherapy and dialysis and expects community health partnerships to continue to accelerate such a shift; recognises the benefits of community casualty units which can help to relieve pressure from busy accident and emergency departments; welcomes the continuing development of new staff roles and expertise as a means to carry services closer to patients; supports the community pharmacy minor ailments service as an excellent example of improved local access; supports the increasing focus of NHS Scotland on reducing inequalities between those with the best and worst health; acknowledges the contribution to improving health of services in local communities for people of all ages, from improving children's dental health in Glasgow to promoting walking for health by older people; applauds the world-leading anticipatory care "Keep well" services which tackle coronary heart disease in the most deprived communities, and welcomes the continued development of local community health partnerships as a strong and coherent response to the changing pattern of demand that NHS Scotland will face."
The motion is hardly a masterpiece of brevity, but it highlights a number of innovations in the health service that we all welcome. It is an end-of-term report that celebrates significant achievements so far but chooses to ignore several areas of underachievement.
We all signed up to the broad thrust of Professor Kerr's vision of how the NHS in Scotland could continue to deliver high-quality care in the light of demographic change and the rising demand for health services—by focusing on primary care, with locally accessible services and an emphasis on preventive care and self-management of chronic long-term conditions—and to the concept that an increase in the range of locally available services would be a positive development in the NHS that would lead to fewer hospital admissions and take pressure off the hard-pressed secondary care sector. As Professor Kerr developed his proposals for the NHS, he consulted widely among professionals and the public. I remember the tangible buzz in the chamber when people felt that at last they were being given ownership of their health service and a say in how it was to develop in the interests of local people.
To achieve the Kerr vision, change is inevitable, but that change must be carefully planned, with the agreement of local clinicians and in consultation with the local population. If service change is to be acceptable and to gain the confidence of the public, new services will need to overlap with existing ones as part of the change process. As the British Medical Association says:
"It is misguided to believe that hospital services can close with just a promise that there will be new services in the community to replace them … NHS Boards must find ways to demonstrate that patients will not lose out because of changes to the way services are delivered."
Unfortunately, service reconfiguration so far has had major setbacks because the public and professionals have not been properly engaged in meaningful consultation and, across the country, people have been faced with decisions to close existing local facilities when they are unconvinced that service provision will continue at an acceptable level.
Does the member agree that in both cases to which she refers the clinical governance committees supported the configuration changes that boards were making? Community casualty units will be developed before any changes to accident and emergency services take place.
I accept what the minister is saying, but I am sure that he will agree that there is a public perception that people are not being listened to. There have been many instances of hospital facilities being closed, and people are not happy with what is happening.
Will the member take an intervention?
No, I must make some progress.
There is an increasing sense of dissatisfaction with the way in which boards consult the public, and a feeling that outcomes are generally predetermined and do not take public opinion into consideration. The focus on community provision is welcome, but it is important to retain a sustainable number of local acute beds and services. Often, doctors and residents are not convinced that that is being done.
The recent BMA survey of doctors showed that there is consensus that local services should be tailored to local need and that if real benefits are to be delivered to patient care there must be engagement with clinicians in both primary and secondary care sectors. The efforts of community health partnerships to create joint working between health and social care are progressing well but, so far, according to doctors, they have failed to engage effectively with clinical staff, which is not helping to achieve a smooth transition between hospital and community-based care. There must be collaboration between the primary and secondary care sectors. That will be achieved only if service redesign is clinician led and the focus is on improving patient care.
Other significant barriers to shifting the balance of care to local communities are inadequate infrastructure and insufficient human resource. For all that there has been
"unprecedented investment in primary and community care premises",
in three out of four practices premises are still not suitable for future needs. Many health centres, such as one that I visited recently in Inverurie in Aberdeenshire, cannot absorb any further work simply because they lack the rooms and space to allow them to expand their activities. That problem must be addressed if a transfer of care from hospitals to the community is to be achieved successfully.
Furthermore, primary care teams are already fully stretched, without the added work that a community focus will place on them. The Royal College of General Practitioners tells us that one in three GPs will retire in the next few years, with a projected deficit of 500 in Scotland by 2012. The Royal College of Nursing warns of the need to retain the experience of its aging workforce, and to recruit for expansion, not just replacement. Many new entrants to primary care—of both sexes—do not see it as a full-time occupation and branch out into other medical or non-medical pursuits. At the moment, the system is propped up by locum GPs, many of whom are several years beyond retirement. According to Audit Scotland, nurse staffing levels are insufficient to cope with sickness and absence or to allow for the development of leadership skills.
There are huge positives in Scotland's NHS, thanks to a dedicated workforce that punches well above its weight. The Scottish centre for telehealth in Grampian has pioneered some groundbreaking work in bringing specialist advice to remote and rural areas and has let many patients remain in their local communities when previously they would have had to travel long distances to a hospital. The provision of treatments such as dialysis and chemotherapy in cottage hospitals makes a huge difference to the quality of life for patients. Of course, health promotion is essential if we are to overcome the major risks to our population from obesity, lack of exercise, smoking and all the ills that we know currently beset our society.
We agree with the Executive that health inequalities have to be addressed with some urgency, and we hope that the keep well initiative will have the successful outcomes the minister has predicted, but we do not think that the current top-down, tight political control of the NHS is the best way ahead. We agree with the BMA that, for the health service to be truly effective, it needs to be driven by clinical need rather than by the need to respond to centrally imposed targets.
It is right that, in the light of changing patient needs and an aging population, we should focus on shifting the balance of care, but any changes to the delivery of care must be planned and sustainable, must involve professionals and the public, and must be in response to clinical need rather than to political control. I am confident that, with empowered patients and their GPs at the centre of the NHS, services would develop to meet their needs.
I move amendment S2M-5572.3, to leave out from "congratulates" to end and insert:
"however recognises the importance of retaining a sustainable number of acute sector beds and services and recognises continuing public concern over the extent of proposed centralisation of hospital services; congratulates the NHS where it has established innovative approaches to meeting modern day demands such as the use of tele-medicine in Grampian and Orkney and the shift of chemotherapy and dialysis to the local community; recognises the increase in funding for the NHS however notes that despite this substantial increase there are still many issues to address; supports the Scottish Executive's focus on health promotion and reducing inequalities between those with the best and worst health however believes that patient need would be best met with more purchasing power being placed in the hands of patients and GPs so that their choices determine the development of the service, and also seeks to develop a health service driven by clinical need rather than responding to centrally imposed targets."
This is an important debate, particularly if it really does mark a sea change in public policy. My party has long wanted a new emphasis on, to use the words of the Minister for Health and Community Care's motion, a shift in the balance of care away from episodic care in the acute sector to health promotion, preventive and anticipatory care. That is not to suggest for one moment that there should be poorer standards of treatment for those who fall ill, but rather that we should seek to ensure that far fewer people require treatment, because they are living healthy and fulfilling lives.
As the minister said, it is not as if the Scottish Executive has not made progress already in changing the emphasis, notably, but not exclusively, with the ban on smoking in enclosed public places and free eye and dental checks, all of which Liberal Democrats have consistently advocated.
The minister listed a number of other initiatives from keep well services—I commend him on his announcement today of extra resources for that—to child dental care, which are truly making a difference. As we know, most interaction between NHS Scotland and the population it serves is in community health. It was therefore important that the Kerr report should underline that and that "Delivering for Health" should point firmly towards making NHS services more local.
We need to cut waiting times by ensuring local provision and by promoting better health, so that fewer people are waiting. It is important to recognise, as the motion does, that there has been a 50 per cent increase in funding for primary medical services and major investments in primary and community care premises. As has been said—and as all parties acknowledge—significant innovations have been taking place in telemedicine. I am sure that we all wish the Scottish centre for telehealth in Grampian every success and that we will all watch the development of the teleneurology service in Orkney with interest.
There are many other significant developments. For example, in July 2006, the community pharmacy-based minor ailments service was introduced. Patients who are exempt from prescription charges can register with a community pharmacy of their choice and have any minor illnesses or common conditions treated by the community pharmacist on the NHS. That means that patients no longer have to bother their GP for a prescription for a relatively minor condition. My understanding is that 660,000 patients have registered for the service and that community pharmacists are providing roughly 50,000 consultations a month. We should all record our thanks to community pharmacists for the effort they have put into an excellent example of making health care more local.
I will extend the member's point about the role played by community pharmacists. Given the experience of the coeliac breakfast this morning, does he agree that it might be a good idea to take the concept and extend it to access to the special foods that coeliacs need?
Yes, I see no reason why community pharmacies should not be involved in that, in co-operation with others who retail such products.
We can do so much more to improve the health and well-being of the nation. Lives can be made better if we develop anticipatory care, improve the speed of diagnosis, deliver services as close to the patient as possible, and support and work in partnership with colleagues in social work and social care and with voluntary carers.
My party believes that the health and well-being of the nation has NHS Scotland at its centre, but we further believe, as we said last autumn in our pre-manifesto, "Bright Future—A Vision for Scotland", that every aspect of government needs to be focused on the links between public health and the environment we live in.
Access to quality green space, having a warm, dry home to live in, the ability to cycle safely instead of using a car and having clean air to breathe are all important in the promotion of health and well-being. Much work has been undertaken in our schools as part of the hungry for success programme, but we need to promote that concept throughout the public sector.
As we said in "Bright Future", government too often contradicts itself—it is no good preaching healthy eating to people if the state still sells fatty, frozen and processed food. We call for protection for our green spaces, for improvements in building regulations, for the central heating programme to be extended to cover the replacement of obsolete systems and for the needs of carers to be covered. We should do all that to improve the lives of individuals. We should never lose focus on the fact that too many of our fellow citizens are burdened with ill health. It is right that we look abroad for fresh talent, to people who wish to devote their careers and their lives to this country, but we must not forget the hidden talent that exists among our own people who are burdened unnecessarily.
Many members will have been to the coeliac reception that took place earlier today. One of the participants in that event told me that, within a fortnight of being diagnosed and a change in diet, she felt a great deal better. She realised that her earlier life had been like driving a car with the handbrake on. By making our health service more local, preventing ill health and promoting health and well-being, we will allow the hidden talent in the nation to flourish.
Let us take the handbrake off the lives of many of our fellow citizens. Such action is important for the economy. Just less than 9 million scheduled work days are lost every year because of ill health. The "Scottish Economic Report" recently showed that a 5 per cent increase in regular physical exercise could reduce the number of days lost through sickness by 7 per cent and save 157 lives, thereby reducing the cost to the NHS by millions of pounds each year. That single example demonstrates the boost to our economy that improving our nation's health would give.
Over many years, health policy has focused on inputs: more doctors, more nurses, more buildings, more treatments, more this and that. They are all important and it will remain necessary to develop community health facilities and NHS workforce planning as crucial parts of making health care local, but the outputs are what really matter for individuals and they need to be our focus now.
I hope that, in years to come, this afternoon's debate will be viewed as a seminal moment when we all chose to concentrate on identifying areas where ill health is profound, on helping people to change their lives, on anticipating illness before it strikes, on improving diagnosis and on getting treatment to people early, so that they do not have to plunge too far into the acute sector. That is what making the NHS in Scotland more local is all about and I commend the motion to Parliament.
I thank the back benchers whom I am about to call for agreeing to reduce their speeches to five minutes. It will be a tight five minutes. Some members are looking at me as if they have not agreed to that.
I am looking a little puzzled because we were originally told that we would have less than five minutes, so five minutes seems quite generous.
Most members are only too well aware that the public are concerned about the perceived centralisation of health services. It is an unfortunate fact of life that although the removal of services happens relatively quickly, any promised roll-out of compensatory services seems to take much longer.
I am a veteran of the Perthshire campaign to retain consultant-led maternity services at the Perth royal infirmary, which was at its height when Susan Deacon was the Minister for Health and Community Care. There was no end of public involvement—which, in general, was viewed as an infernal nuisance by the health board officials—but at the end of four years of consultation, the outcome was exactly the one that the health board wanted in the first place, despite the opinions that the people of Perthshire had expressed clearly and frequently. I sat at a meeting at which a health board official publicly stated, using almost these very words, "It doesn't matter if everyone in Perthshire wants to retain consultant-led maternity services—it is not going to happen." That was during the consultation process.
It might be a coincidence that the debate is being held just two weeks after the Parliament voted against Bill Butler's member's bill on direct elections to health boards, but we have some way to go before we can convince people that they are being listened to and are having their views taken into account.
The Executive motion contains a great deal with which I agree, and the SNP's amendment reflects the extent of the consensus, but our amendment specifically acknowledges the difference between core acute services and the more specialist services. It is when core acute services are to be affected that tension really arises.
Contrary to what is sometimes said, most of the people to whom I speak do not expect a hospital at the end of every street. Nor do they expect that highly specialised areas of medicine should, or even could, be available in every locality. Frankly, it is insulting to ordinary people to suggest that they do not understand the difference between the two kinds of health care. What people expect is that certain core services will be made available as locally as possible. They include in those core services the provision of maternity and accident and emergency services, about which there has been a lot of controversy.
As Shona Robison said, and as the member has pointed out, the SNP recognises the benefit of community casualty units. What communities would have a community casualty unit and what communities would have consultant-led accident and emergency units?
It is a pity that Duncan McNeil did not intervene on Shona Robison with that question. As he may well imagine, my comments will be more narrowly focused on my constituency. It is important that we take people's views on board. Unfortunately, people do not feel that that has happened so far.
It is also important to make the decision-making process much more transparent. For example, when decisions are made about how many prescribing chemists are appropriate for a community, what criteria are used and what weight, if any, is given to local opinion? If pharmacists are going to play the more central role in the delivery of health services that all of us agree is appropriate, the number of pharmacies that are available in a local area will become more and more important. I can see the beginnings of a problem that needs to be sorted out before it becomes a major irritation. I may take up the matter separately with the Minister for Health and Community Care, because there is a specific issue that needs to be dealt with.
The minister will remember that I raised with him the number of minor illness and illness units in Perthshire and, more specifically, the lack of such a unit in Auchterarder, despite the existence of St Margaret's, the excellent local community hospital. He made a welcome comment when he said that he appreciated the point about
"pressures elsewhere in the system, which I want NHS Tayside to monitor closely. I want NHS boards always to review the provision of services, so that we can allow change to occur as appropriate to community needs."—[Official Report, 1 February 2007, c 31740-31741.]
I should point out that the "extensive public involvement exercise" that the minister quoted NHS Tayside as having undertaken did not include any direct consultation with the people of Auchterarder and its catchment area on the potential for an MIIU at St Margaret's. Without such consultation, it is understandable that health board officials do not realise that the seven miles from Auchterarder to Crieff—the location of the nearest MIIU—are along unlit, winding roads that would never be the first driving choice of anyone seeking help. Given that the bus service between Auchterarder and Crieff is of the Tuesdays, Thursdays and Saturdays variety, public transport does not fill the gap. The bus service does not exist on Sundays. Even on the days when there is a bus service, the timetable ends around 5pm. From the other areas that would use an Auchterarder MIIU, there is simply no direct public transport provision to Crieff—none at all. In making those comments, I am aware that I have focused on my area, but the same issues and problems will apply in many areas of Scotland.
I appreciate the difficult challenges in all of this, but they are part and parcel of what must be taken into consideration if the desire to make the NHS local—a desire that we all share—is not to founder in the implementation. Too often, it does.
As the minister outlined, the Executive's health policy, which it set out in "Delivering for Health", and the main recommendations of Professor David Kerr's well-received report, are moving in the same direction—we must continue to improve and deliver health services at the local level.
I want to show how primary health care provision in my constituency has improved, although of course we have more to do. I am presently working hard to improve further health centre provision in my constituency, such as at Doune, where proposed new housing will put more pressure on existing facilities.
I will start with the example of the Balfron health centre. In 2005, NHS Forth Valley carried out a £600,000 upgrade of the centre to meet the needs of the expanding population in the area, which is currently around 2,500. The clinic accommodates a full primary care team, which comprises two general practitioner partners, two assistants, a GP registrar, a practice nurse—the list goes on. The clinic also hosts dermatology outpatient clinics from Forth Valley dermatology services—just the type of provision that the minister described. Balfron health centre is a new model of care that aims to provide care closer to people's homes, thereby reducing the need to go to hospital.
My second example is at Buchlyvie, where a brand new state-of-the-art primary school and medical centre was officially opened in October 2006. The £1.3 million extension and refurbishment project brings together under one roof the local primary school and medical centre. I gather that it is the first of its kind in Scotland. It is the first joint project between Stirling Council's children's services and NHS Forth Valley, and it provides a valuable combined resource for the whole community. The building boasts a number of shared facilities, including a reception, a visitor waiting area and meeting rooms. It also has purpose-built consulting and treatment rooms and a dispensary, to give local residents a convenient and comfortable environment.
Callander medical centre, which saw its first patients in January, is the first new health facility to be built in the Loch Lomond and the Trossachs national park. The £2.4 million GP practice is taking an holistic approach to health, with person-centred psychology among the additional services being provided. It will also be used by Stirling Council as a much-needed day centre. Some of the new services, including a dermatology clinic, will be used by patients from the whole of the north-west area of NHS Forth Valley. Patients groups such as Callander diabetic patient forum, which is an NHS Forth Valley clinical effectiveness prize-winning initiative, will now be able to hold their meetings in the purpose-built meeting room. Trossachs Pharmacy will also be located in the new medical centre. We like to showcase our new facilities, and I invite the minister to visit some of the health centres in my constituency when he can, to see the work at first hand.
Orchard House is part of the Raploch regeneration project in Stirling. The NHS board is providing a comprehensive primary care facility in the area. The new community health complex at Orchard House will provide space for six GP practices, making redundant some of the current Victorian clinics. Co-locating GPs with other community health services, such as dentistry, on the new health campus will bring significant benefits for patients. The work on the full business case continues.
Another arm of the Executive's work in improving our health is the whole government approach to health improvement in Scotland, involving work in schools, increasing recreational opportunities and, most important, improving the quality of the environment in which we live. The minister mentioned most aspects of that approach, which includes priorities on improving diet, increasing physical activity and reducing alcohol consumption and smoking. I could list the many smoking cessation initiatives that are going on in NHS Forth Valley. There is also the Stirling Health & Well-being Alliance, which provides afternoon drop-in sessions for support groups in areas of social disadvantage. Community health partnerships and public partnership forums are playing their part in moving the local health care agenda forward. I could detail some of the important areas that they have been considering.
The infrastructure relating to improvement at the local level—the buildings and the professional services—is moving ahead well in the Stirling constituency. It is important that, as well as keeping an eye on present and future needs, we celebrate those achievements. I support the motion.
I draw members' attention to my amendment, which unfortunately was not selected. It is a fair summary of what I would like to say, if I do not have time to say it all.
It is important to place this debate in the context of wider social and economic policy. The UNICEF report that was published this morning should pull us all up by the bootstraps and prompt us to ask whether policy in this country is effective. The difference between countries that have adopted neo-liberal economic policies and those that have more social, public and progressive taxation policies, such as the Scandinavian countries, is staring us in the face in the report's statistics. All the main parties in the Scottish Parliament need to think about their economic policies when they make proposals, for example on reductions in corporation tax.
Last night, I attended a debate organised by the Policy Institute. Unfortunately, I was the only MSP there. While I disagreed vehemently with some of the right-wing conclusions, particularly by a columnist from The Sunday Times, at least the ideological debate about the future of the NHS is happening out there. It does not always happen in here. Sometimes we deal with the detail, when the future and strategic direction of the NHS are what are at stake. It is under fundamental attack. The right wing agrees about that, when it is honest about chipping away at the NHS with further market reforms and privatisation, but it is quite difficult to get those issues debated in the Parliament.
I will move on to specific issues, as I do not have much time. My amendment refers to capacity. We need capacity, capacity, and capacity.
Where is the evidence for the alleged privatisation of our health service in Scotland? We have the Stracathro centre and other private initiatives, which account for about £140 million of the £10.2 billion health service budget. The PFI and public-private partnership elements of our investment programme amount to less than 20 per cent of our building programme.
The Scottish health service might be moving towards privatisation at a snail's pace compared with the English service, but it is still moving in that direction, otherwise why did the Executive introduce legislation to enable that to happen? We are the PFI capital of Europe. The minister knows that Serco recently made a serious attempt to grab primary care services in Harthill, facilitated by legislation that the Executive put through the Parliament.
The NHS does not collate enough statistics for workforce or bed-number planning: it is not planning sufficiently. The new consultant contract has been introduced, but the planning for the number of hours that are available for patient care has not caught up with the contract's implementation. The royal colleges are now saying that, because of the contract and other initiatives, such as modernising medical careers, to meet the demand in the service we will need 1.7 consultants for every consultant who is currently employed. That is a huge increase, and I am worried, because I see no sign of the investment that is required to achieve it.
NHS Lanarkshire made a commitment at the beginning of a consultation not to change bed numbers, even though the demography and demand in the area are changing and there is no scientific—
Ms Leckie, this is a debate on making the NHS local. I have not yet heard that word, so could you make something local?
I am talking about the capacity to deliver services locally—and anywhere else. If the NHS does not have the capacity, nobody will have any local or distant services.
The issues that face the NHS are capacity, privatisation and the question of which strategic direction it will take. The NHS has also been reorganised to death. There has been a new reorganisation every two years in some areas—there have been six in 12 years—but some of the managers who implement those reorganisations have been in post for only two years. Members should compare that with the length of service of consultants, medical staff, nursing staff and allied health professionals. There are real questions about whether the changes that are introduced are the right ones. Who is involved in and consulted about the plans? Are the changes measured before the managers up sticks and leave?
I have not been able to go into enough detail. There is a debate—which we should be having—about whether we will sustain, protect and reinforce a universal, comprehensive, high-quality service that is free at the point of need. There is nothing in the minister's policies that assures me that he will do that.
I warmly welcome the announcement from the Minister for Health and Community Care on the embedding and extension of keep well integrated, anticipatory care in local communities, which is already benefiting my constituents in Leith, Pilton and Granton.
The keep well initiative is a key new part of the NHS's action to close the gap between the richest and the poorest, which is at the heart of the Executive's health policy. It is one of many exciting developments in integrated local care, many of which are mentioned in the motion, including dramatic improvements in the management of long-term conditions. One example that I read this week is that the optimum control of cholesterol levels in the Lothians has increased from 20 per cent to 75 per cent over the past 10 years. Many other examples could be given, including the exciting development of partnerships with the voluntary sector that the Minister for Health and Community Care emphasised in his speech.
There have also been dramatic developments in the provision of local facilities. I am pleased that the minister mentioned the Leith community treatment centre, which I know he enjoys visiting. The centre has performed invaluable work for my constituents during the past three years. It has not just sorted my back; it has provided community-based teams and a community-based consultant, who offer regular appointments and community-based access to diagnostics. The centre is warmly appreciated by my constituents in Leith.
The emphasis on anticipatory care that underlies the keep well programme was a key recommendation of the David Kerr report, which set out a more general vision in which continuous integrated care in local settings would take over as far as possible from reactive, episodic care in acute settings. One of my most important actions as Minister for Health and Community Care was the appointment—indeed, the hand picking—of the members of the David Kerr group. The clinicians, managers and patient representatives who formed the group were committed to the delivery of the maximum possible amount of care in local settings. The group delivered the blueprint and "Delivering for Health", which followed, took the general approach that they had recommended. Members of the Parliament signed up to the David Kerr report.
I have been interested to learn that many people across the border have been taking a great interest in the David Kerr report. Two or three weeks ago, I saw an advertisement in the Health Service Journal for a conference in England—where there is much controversy about the reconfiguration of services—at which a session on learning lessons from Scotland was to be led by David Kerr and a senior official from the Health Department. It is unfortunate that Opposition parties in the Parliament have not always learned the lessons in the David Kerr report—that might not be obvious in this debate, but it was obvious in the most recent parliamentary debate on health.
A great deal remains to be done to make the NHS local. The motion mentions the role of community health partnerships. CHPs were a key development in the National Health Service Reform (Scotland) Act 2004, which was passed after the most recent election. They are delivery agents for shifting the balance of care further, as the motion emphasises, and we look forward to their further development in that regard. CHPs will also be agents for more local decision making. I was interested to read that during the past couple of weeks NHS Lothian shifted the management of more front-line services to CHPs. CHPs are at the cutting edge of approaches to decentralise care and deliver it more locally.
I hope that members and people further afield appreciate the strengths and achievements of the Scottish health system. Last week, I spoke to a senior clinician who has just moved up from England, who said, "You have a better system here. It is more integrated." Integration is the key word for the Scottish health service. We should appreciate the benefits of our system and, more important, we should appreciate the delivery that we have witnessed during the past few years. Tributes should go to the Minister for Health and Community Care, to the Health Department, to NHS boards throughout Scotland and, most important, to NHS staff throughout Scotland for their total focus on delivery, which brings spectacular results.
I worked in secondary care for 10 years and in primary care for 25 years and I always thought of primary and secondary care as a team that works to provide very much the same service. As we push more activity into primary care, we should praise the people who, for generations, have been trying to prevent illness as well as dealing with acute services. Preventive work, which is extremely labour intensive, has been going on in primary care. We improved the figures on blood pressure, asthma and diabetes and we encouraged healthy eating and healthy lifestyles in the 1970s, 1980s and 1990s. I support the approach, but it is not new.
If we are to look after the public in the community, we need accommodation and highly trained staff. The community is not a ward; it takes time to visit people in their homes and make decisions. Staff need time that is dedicated to learning and keeping up to date.
Safety is important. We have to think carefully before we close a service and move people to a new one. Transition is an important time, and training is required.
Pharmacies will be playing a more important role in future. I have no objection to that, but proper accommodation will be required. Health boards will have to check that accommodation is up to standard and that people will have privacy. Pharmacists, just like doctors and nurses, should be given time to dedicate to keeping themselves up to speed.
Margo MacDonald mentioned a coeliac breakfast this morning that was attended by Andy Kerr. When I was a young doctor, I knew about coeliac disease; it was always in the back of my mind as an alternative diagnosis. However, at the breakfast I was shocked to learn that—perhaps because of the way the system operates—coeliac disease is not being recognised. People are having to wait a long time to be diagnosed with some chronic conditions. Those making the diagnoses have to have the time to do so.
There is nothing wrong with midwife-led units, but from my years in anaesthetics I know that there can be problems if women do not have the right antenatal care and are not treated well at the various stages of pregnancy. If someone holds on to a patient too long, there can be a precipitate birth, a stillbirth or an intra-uterine death. There can also be third-degree tears. Some time back, part of anaesthetists' lists was to repair such unpleasant incidents that occurred during delivery. Men do not know anything about that sort of thing but, sadly, women do. Clinical need and patient safety should be at the root of every single decision.
We need the right numbers of people. Nanette Milne talked about nurses, doctors and other experienced people retiring. Back in the 1970s, when the Salmon report was implemented, experienced ward sisters were taken out of the wards. They were given a higher salary, but they were no longer where the action was taking place. We had to be careful before sending a child with appendicitis back to the ward, because young and inexperienced nurses would be looking after them.
We cannot close beds until we are sure that they will not be needed, and we need to know how many beds we have. We cannot change any service until we know what will be put in its place. Buildings will be required, but it is not buildings that make things happen, it is highly trained people. We have to keep that idea at the forefront of our minds, because how we implement the Kerr report is the most important issue. As I said at the beginning, it is how we implement measures that makes them succeed. It will take time.
NHS Highland has recently agreed to submit a proposal to the Minister for Health and Community Care seeking legal permission to close Glencoe hospital, which is a small cottage-type hospital serving south Lochaber. It has provided valuable and excellent services to its community for decades.
I have sought to play a role in advising members of the affected community about changes. I have met community council representatives and arranged for them to meet Garry Coutts and Roger Gibbons, the chairman and chief executive of NHS Highland, on 5 February—last Monday. The community is not saying that the hospital must at all costs stay open for ever, but the community wants any alternative arrangements to be as good as, or better than, the existing arrangements, even if a different model of provision is required from that offered by the old-style cottage hospital.
We are working with the members of the health board management team, who have been willing to meet us, and I hope that they will agree to meet the community council representatives again. Between them, those representatives have more than a century of public service. They know their area. We wait to hear whether the health board management team will meet the representatives again. I suspect that they will.
It is the detail of the alternative plan that is hard to put in place. Arrangements are having to be made with a private home, which needs to be converted to provide nursing care in addition to the residential care that it provides at the moment. I am referring to the Abbeyfield home in Ballachulish, which requires adaptations to be made to the building. The car park is not big enough. Planning permission is required. Nurses who work in Glencoe hospital need training to provide a different type of nursing care. That all takes time. The ambulances that are now housed at the cottage hospital will have to be moved. Premises will have to be found, and planning permission will have to be obtained for that, too.
In addition to those difficulties—all of which can be addressed—there is the question whether the alternative arrangements will be robust in the long term. Looking at the wider picture, the population of Lochaber is set to remain the same—between 18,000 and 19,000—over the next 20 years. However, over the same period, the population of over-75-year-olds is set to double, from about 1,300 to 2,600. Plainly, the need for nursing places will be greater in years to come, yet the provision is to remain at the same level.
We all want care to be provided in the community and at home, of course, but that brings problems with it. The financial responsibility for that rests largely with the local authority, which requires joint work between the local authority and the local health board. Ministers will be well aware of all those matters, and I do not want to make this speech too parochial, but I suspect that the difficulties that apply to the situation at Glencoe will apply in many other parts of Scotland.
My plea to the minister, when he considers the proposal, is that he should be willing to consult the local communities about the details and the minutiae of the change and that, before considering the application, he should ensure that he is absolutely satisfied that the alternative proposals satisfy the legitimate needs and aspirations of the people whom Glencoe hospital serves.
I urge the minister to consider the recommendations of the Health Committee about the difficulty of finding medical personnel, especially consultants, including at the Belford hospital, and even at Raigmore hospital. That is perhaps the greatest problem of all. The colleges must be more flexible in relation to the ways in which we can encourage people from Lochaber to become doctors. They are far more likely to want to go back and follow such examples as David Sedgwick, who is so respected as a rural general surgeon. I know that the minister is sympathetic to those ideas. I hope that, together, we can all work towards implementing them, so that the NHS can be delivered locally in my area and throughout Scotland.
Roseanna Cunningham and Sylvia Jackson both described the special circumstances in their local authority areas. I was especially interested to learn about the dermatology services that Sylvia Jackson spoke about. That issue is close to my own heart, and I hope that such services can be replicated in other parts of Scotland.
Sylvia Jackson did a splendid job outlining how the NHS in her area is going local. The rest of us can see similar good developments in our areas. I listened to what she said with real interest and admiration. It appears from what is happening in her constituency—like in many other constituencies—that decision makers and professionals are showing real dedication. Sylvia Jackson is right that we must celebrate that commitment and ensure that our health service in Scotland is one of the best in the United Kingdom.
It really was unworthy of Carolyn Leckie to suggest that, because some MSPs with a health interest were not at the same meeting as her last night, we did not have an interest. The fact is that I was attending a health meeting in my local community in Dunfermline. MSPs simply cannot be there at—
Will the member take an intervention?
Not at the moment.
On PPP and the private finance initiative, I point out to Carolyn Leckie that only 17 per cent of the capital spend is spent on PFI and PPP projects—83 per cent of capital spending is for public capital projects. Without PPP and PFI, the hundreds of new health service facilities that we are building simply would not exist. It would have taken decades to develop some of them.
When she spoke about hospital beds, Carolyn Leckie made no mention of the way in which medicine has moved on. She did not mention that we no longer need to keep patients in hospital for as many days or weeks as we used to. The new keyhole surgeries, the way in which we now treat people and the new science are bringing dramatic change to patients, not just by prolonging their lives but by vastly improving their quality of life. Carolyn Leckie was being quite disingenuous.
Malcolm Chisholm reminded us all why we signed up to the Kerr report and to the Health Committee's work, in particular its workforce planning inquiry. He gave us a real understanding of the education, training and institutional issues.
However, I remain puzzled as to the SNP's big picture vis-à-vis accident and emergency services throughout Scotland. What is its policy? Whatever we decide today, we need to know that. It is easy for the SNP to say what it would do in Lanarkshire, but what would it do throughout Scotland? It has singularly failed to answer that question here or anywhere else. How does that fit with the fact that Shona Robison and Roseanna Cunningham signed up to the findings of the workforce planning inquiry? The inquiry recognised why many decisions had to be taken. Because in Scotland we have lacked local consultants and specialists, we have had to reconfigure services.
As Nanette Milne said, it is vital that we include the professionals. There must be a triangle of consultation that involves the professionals, patients and politicians. That is critical.
I have lots to say, but I will not do so, in the interests of brevity. Today, we must send out the message that we praise and celebrate the work of our health professionals, no matter whether they are pen pushers, civil servants such as those at the back of the chamber, or people who are delivering front-line clinical services. We praise and thank them on behalf of the people of Scotland.
Because I am going to quote from the British Medical Association's briefing later, I should declare that I remain a member of that organisation.
Nobody is going to argue with the concept of making the NHS more local while retaining more centralised services for specialist areas. However, while the concept is sound, it is noteworthy how many debates there have been in this Parliament on the closure of cottage hospitals, maternity units and so on, not to mention Lanarkshire accident and emergency units. There is still a failure of engagement with the public.
We also have debates about the many facilities that have opened in Scotland as a result of the changes. For every hospital that is closed in Scotland, there is an alternative service and alternative provision. Many hospitals that have been closed were simply unsuitable for modern healthcare, particularly in the mental health arena.
Absolutely. I am not saying that I would not have closed any hospital or hospital unit. I have never said that. What I am saying is that there is a failure of engagement with the communities whose health needs the facilities are supposed to meet. The problem is not whether I think that they should close; it is whether the public have engaged with and been taken on the journey that the Executive is going on in relation to the health service.
The motion and amendments all contain examples of approaches that are seen to be working, but we must pay heed to the note of caution that is sounded by the Royal College of Nursing in its briefing, which focuses on key nursing workforce issues that need to be considered to help make the NHS more responsive to local needs. It refers to the need to set an appropriate predictable absence allowance to ensure that staffing levels can cope with staff sickness and absence. It would be helpful if, in his closing remarks, the minister addressed that, the issue that the RCN mentioned about supporting and retaining older nurses, and the issue about reducing the drop-out rate of student nurses, given that the Executive has indicated to me in a written answer that there is no intention to increase the bursary for student nurses in the near future.
The Royal College of Nursing also talked about the new model for community health nurses. That takes me back, hauntingly, to the nurses with whom I worked 20 years ago, when I was a school doctor. Particularly in rural areas, those nurses combined the role of health visitor, district nurse and school nurse and, sometimes, the role of community midwife as well. The new role of community nurse, which will combine the role of health visitor, school nurse and district nurse, seems to be a step back towards those days. Twenty years ago, the Highlands—where the new scheme is being piloted—moved as quickly as funding would allow to have dedicated nurses with single duties, who were either health visitors or district nurses or school nurses. We knew, from the experience of having nurses with more than one duty, that the health promotion side of their work was always displaced by things that were no more important but were more urgent. Elaine Smith mentioned breast feeding. We need health visitors to support mothers to continue with breast feeding. I fear that the skills of each of those groups of nurses could be lost when all of the roles are subsumed into the new post. I would like an assurance from the minister that the pilot will be fully evaluated before the model becomes universal.
With regard to my exchange with the minister earlier, I quote from the BMA's briefing, which was given to all members:
"It is misguided to believe that hospital services can close with just a promise that there will be new services in the community to replace them. The funding for these new services cannot be released until hospitals lose a portion of what they are currently funded to provide."
Will the member give way?
No. I am sorry, but I am in my last minute.
The BMA continues:
"The BMA believes that no significant changes to existing hospitals services should take place before there is agreement of clear plans for alternative services in the community, and full details of the interim arrangements that may be necessary."
I agree with that. The crucial point is not that things should never change, but that people should know what alternative services will be in place.
Making the NHS more local is a welcome development and the benefits are especially obvious in rural areas, where travelling to a specialist unit can be much more difficult. However, the key driver for the work must be improvements, not savings.
The Liberal Democrats have long advocated shifting the balance in the NHS away from reactive care in the acute sector towards preventive, integrated and continuous care in local communities. We fully support what the Scottish Executive is implementing.
The thrust of Professor Kerr's report, "Delivering for Health", which was welcomed by all the political parties, was that we had to change the way in which we delivered care in Scotland. The report said that there should be more effective accident and emergency centres, that local community casualty units should be introduced, and that planned care should take place more locally in community facilities.
I am therefore particularly surprised by the reaction that we heard today from the SNP and the Conservatives to the Executive's proposals for reforming health care in Scotland.
Will the member take an intervention?
Not at the moment. The member will have to let me speak a little first; then I will be happy to give way.
In his opening speech, the Minister for Health and Community Care explained how the Executive plans to implement the changes that we need to make as a result of the Kerr report. He emphasised how important it is to engage patients in the delivery of local services.
Shona Robison started well. She largely supported the Executive's motion even though her amendment to it is almost as long. However, in response to my intervention, she implied that the SNP would retain all accident and emergency units despite the medical profession's view that we cannot support them all.
Is the member aware of the recent report by the Royal College of Surgeons of England, which recommends that accident and emergency departments should serve a minimum catchment of 300,000 people? Would the member support the translation of that model to Scotland, given that that is the view of the clinicians? If so, which nine hospital accident and emergency units would he close?
I am disappointed by that response. The member knows that the Scottish Executive does not support that approach and that the Liberal Democrats do not support it. I would have expected the SNP to have cottoned on to the fact that the geography of Scotland is different from the geography of England. It is about time the SNP grew up.
For the Conservatives, Nanette Milne focused on what she said was a lack of confidence in NHS consultations. However, as we know, the buck stops with the minister. I will say more about that in a moment. I am never convinced by the Conservatives' approach to health debates, which always seems to be that doctor always knows best. "Leave it to the professionals" seems to be the view of the Conservatives, who ignore the patients.
The member contradicted himself. He said that the SNP must listen to clinicians, but then he said that we Conservatives should not listen to doctors. Who is he kidding?
Phil Gallie must listen. I did not contradict myself. I said that the Conservatives' approach is that the doctor always knows best.
My colleague Euan Robson mentioned the preventive health measures that we implemented in the current session of Parliament, including the ending of smoking in public places, which is a real move forward, and the legislation that allows free eye and dental checks. Those are excellent initiatives. The free eye check, for example, is not just the sight test that we used to have. It is a proper medical check that examines people's eyes comprehensively and looks for problems to solve. It is all about preventive medicine.
Roseanna Cunningham said that the health board in her area could do what it liked about withdrawing consultant-led maternity services. I return to the point that health boards do not have the last word. The minister also has responsibilities and, as we have seen with his intervention on maternity provision in Aboyne in my constituency, he is willing to act to ask the health boards to think again and get it right. My experience is certainly different from what Roseanna Cunningham highlighted, and I would like to take the opportunity to put on record again my thanks to the minister for his intervention in that case. The board has agreed to discuss what the right solution is for maternity services in Aboyne.
In her contribution, Carolyn Leckie used the word "local" once. Other than that, her contribution was entirely irrelevant to this afternoon's debate.
In conclusion, we need to reconfigure our health service and make it more local when it is safe to do so. That is the key, it is what Professor Kerr said was essential and it is exactly what the Scottish Executive is doing. As far as I and other Liberal Democrats are concerned, the Executive deserves our support at decision time.
I do not usually get involved in health debates, but I have found today's debate extremely interesting. It has been fairly well balanced and, although we are moving towards elections, the speeches have not been the tub-thumping electioneering that we have been so used to in recent times in the chamber. That is certainly of value.
I am slightly disappointed that Mike Rumbles turned the emphasis on the SNP and played politics with the issue slightly. I do not think that that was necessary, but that was a judgment for him to make.
We have heard from several members who have been professionals in the NHS—Jean Turner, Nanette Milne, Carolyn Leckie and Eleanor Scott. I found their contributions well worth listening to, and I hope that the minister has taken on board their comments, because we should not shut out anyone who wants to speak about health care in Scotland.
I tend to agree with much of the Executive motion. I like the move towards primary health care and prevention of diseases—it is a fair policy. However, I plead with the minister not to turn that agreement back on Opposition members in future, as has happened recently with the Kerr report. We agreed in the main with the Kerr report, but there will always be elements on which we find differences. I do not think that, when we find those differences, it is fair that we should be ridiculed by the minister saying, "Well, you embraced the report and thought it was great, and now you are saying something different." There will always be differences and, although we support much of the Executive motion, we will not embrace it to its fullest extent.
Does Phil Gallie agree with Dr Peter Terry, chairman of the BMA in Scotland, that it is vital not to deconstruct the various parts of the strategy that is laid out in "Delivering for Health" and not to pick and choose elements on which to campaign for or against?
The all-embracing idea that Kerr referred to was localised input and taking account of local ideas and wishes. I do not want to take that away from the Kerr report, but it means that not all the report will be accepted by local people. On that basis, we have to be prepared to be a little flexible. Not everything is black and white, so let us provide a degree of flexibility that meets the needs of local people.
One example is the A and E situation in Ayr, which is very much in my mind, as I am a local representative. I am shattered that the A and E department at Ayr hospital is down for closure, but I welcome the fact that the minister has said that it will be retained until we can be assured that all the changes have been made in a reasonable manner. That is fine, but one thing that is missing from the Executive motion—something that no member has addressed—is the Scottish Ambulance Service. It is very much tied into the situation with Ayr and Crosshouse hospitals. Recently, criticisms have been made of difficulties with the Ambulance Service in the Borders.
Will the member take an intervention?
The effect on that service has always been one of my main concerns in relation to the closure of A and E at Ayr. Perhaps the minister will think about that and refer to it in his reply.
I am sorry; Carolyn Leckie wanted to intervene first.
I thank Phil Gallie for allowing my intervention, which is about ambulances, and for at least listening to my speech. Does he share my astonishment that the Scottish Ambulance Service and the Scottish Executive cannot provide the statistics on the number of ambulances that are staffed on calls by paramedics rather than technicians? If we do not know that, how on earth can we plan for the service's future and depend on ambulances to replace some accident and emergency units?
Okay, I have got the message and I pick up what Carolyn Leckie says. The point that I have made to the minister is that such issues must be examined carefully before any change such as the one that is proposed at Ayr A and E is made. I go along with the points that Carolyn Leckie makes and with her concerns, which I would like the minister to address in the longer term.
One minute.
I would have liked to pick up many issues that have been raised. I noted everybody's speeches carefully. First, I will deal with Jean Turner's speech. She referred to the effect on safety of closing services. She also mentioned the change to pharmacist provision, which I accept is a good move. I considered that some time ago in another place and I favoured it in lobbyist approaches.
Jean Turner referred to accommodation in pharmacies, but I wonder about pharmacies in rural communities, which have difficulties with post offices. I would like to think that we can ensure that rural communities do not miss out on the provision of pharmacists and the services that they provide.
Another important issue that Jean Turner raised was the time element—
You should finish now, Mr Gallie.
I am sorry; I will just close, although I had other points to make. The arguments that Jean Turner made on the time that patients are given when they are treated were important and I ask the minister to note her comments carefully.
The Minister for Health and Community Care started this useful debate with a reminder of where we are coming from. He used the phrase
"as local as possible, and as specialised as necessary."
I heard nothing in the debate from any political party that disagreed with that central tenet of what we are trying to do and that central summary of the Kerr report.
On that basis, I will start with one or two issues on which we agree with the minister. I commend him personally for leading by example in a variety of ways, some of which I will put on record. First, his involvement in the interest of Mr Rumbles and me in maternity services in Grampian was helpful and constructive. It served well the interests of the constituents whom each of us brought to see him. When they went away, they felt that they had been listened to. I hope that other ministers take a leaf out of his book; occasionally, they do not appear to.
I also commend the minister for his personal contribution by leading by example on fitness. If only I still had joints that allowed me to run the occasional half marathon—or was it a marathon? I do not quite remember. For me, a half marathon would have been a marathon, but perhaps not for him.
I thank the minister for his support on maternity services by intervening to correct what would have been a serious wrong for essential local delivery of services in Mr Rumbles's communities and in mine. Of course, I say to Mr Rumbles that had we listened to the clinicians, Aboyne maternity unit would have been closed. He will have to read carefully his contributions to the debate in the Official Report.
Will the member take an intervention?
Very quickly—come on.
My point was that the Conservative approach is that doctor always knows best. Stewart Stevenson knows well that my criticism of Grampian NHS Board was that it always listens to clinicians.
I hear what Mike Rumbles says. Understanding may follow, but probably will not.
There is a tension in the system that the debate may not have explored fully, which will continue to challenge health ministers of whatever complexion. That is the tension between the minister, on the one side, the health board, in the middle, and the community, on the other side. That tension is a difficulty for whoever fills the post that the minister holds. The health board is appointed by the minister and is therefore seen by local communities as largely a creature of the minister—whatever the reality, that is the perception. For that reason, health boards must be much more sensitive in approaching communities when they believe that there is a need to redesign the services that are delivered locally.
Can Stewart Stevenson tell me how the SNP will set up the trusts that it will have throughout Scotland to finance all the capital initiatives? Will they be elected or unelected? Will they be quangos?
I suspect that that question goes a little beyond local services. Helen Eadie can read our manifesto on the subject, and members have heard our finance spokesman talk about how the trusts will be engineered. As someone who held large budgets and was involved in banking, I know how the idea works and that it can work. The argument will be whether it should work, and that will be for the electorate to decide.
Euan Robson made an important point when he said that we must move from focusing on the inputs in health provision to focusing on the outputs. People see the money being spent, but that means nothing if they do not see the services being delivered.
Another tension that the debate has not focused on as much as it might have is the tension between the focus on prevention and keeping people healthy longer, which we are now moving to and which we all support, and the continuing need to drive down waiting lists. I suspect that that tension is something that we will continue to debate.
In his intervention, back bencher Duncan McNeil exhibited tensions that were perhaps political rather than health related. I seem to recall seeing a picture of Duncan McNeil on the campaign line, ensuring that his own local services were not downgraded.
There ain't going to be time—I am sorry.
Community care units are an important part of future provision; indeed, we should have more of them. They may well even serve a useful purpose by being co-located with accident and emergency units, and we should not close our minds to that possibility.
I will briefly give a practical example of the nature of the challenges, some of which are basic stuff. I went to hospital with a constituent who had been savaged by a dog—not too seriously, but seriously enough to require six stitches. We went to the nurse-led local accident and emergency unit in Banff and received a good service. The wound was cleaned, stitched and bandaged and the woman was inoculated against tetanus. The nurse signed the card to say that that had been done, but there was then a 100-minute wait for a return telephone call from a doctor to allow the antibiotics that were required to be prescribed. We have not quite joined the whole thing up. I know that the minister recognises that and realises that we must do something about it.
In response to some of the issues that Helen Eadie raised, I note that the Health Committee did not come to the firm conclusion that centralisation was the right answer. Conflicting views were expressed by various health professionals, and we should tak tent on that.
In today's debate, members have illuminated many of the challenges that remain, talked about some of the successes and touched on areas in which further progress is essential. However, the bottom line is that the debate in the chamber is a lot less important than the debates that local communities are having about the health services that they require in their local areas. I support my colleague's amendment.
I acknowledge that we have had a mainly positive and constructive debate during which members have taken the opportunity to highlight how they believe that we could better continue to make the NHS local, and in the main, they have supported the central proposition of the Kerr report and our response in "Delivering for Health" that we should provide services as locally as possible but as specialised as necessary. It is important to emphasise that those aspirations are equally significant.
When Parliament debated the Kerr report and "Delivering for Health", all parties recognised that we need a new approach to the delivery of health care that recognises and responds to the challenges of an aging population and an increase in the number of people who have long-term conditions. We need an approach that aims to shift the balance of care towards preventive medicine, and to shift the location of services, so that more diagnostic and planned care procedures can be delivered within local communities.
I am sure that we all acknowledge that the future of the health service is about moving from simply treating illness towards giving people in the most deprived areas of Scotland healthier, longer and better lives. We welcome the extension of the preventive care programme that was announced today, particularly in my community of Inverclyde. Can the minister assure me that that much-needed money is earmarked for my community and that it will be delivered in my community as opposed to being lost in the greater Glasgow area?
I certainly can give that assurance to Duncan McNeil and to the other members whose constituencies will be involved in the second wave of the keep well pilot. Indeed, Duncan McNeil will recognise that I also have a bit of a constituency interest in that. Ministers have in place an arrangement whereby the expenditure of those funds is monitored by a group that meets every couple of months. I assure Duncan McNeil that the money that has been provided for the keep well initiative in all health boards will be spent on the keep well initiative in those communities where that expenditure is required.
On the subject of Inverclyde, the minister will recall that earlier, when I suggested that Ayr's accident and emergency unit should be retained, he asked me about the fragmentation of the Kerr report's proposals. In fact, the minister fragmented them when he retained the Inverclyde facility. Does he balance that out?
What Phil Gallie has described was an action of the board, not an action of ministers. The point is that the Kerr report says that there are principles that should be applied across all services, but subject to a process of consultation. As we have heard this afternoon, the process of consultation and consideration by ministers will respond to the points made and do so in the most effective way. The Kerr report is not a prescription that says, "This will always happen in all circumstances." It recognises that there will be variety. It is also important to stress the fact that the BMA and Professor Kerr emphasise that the Kerr report cannot be taken in bits; it must be taken as a whole and as a complete strategy. That is what Parliament supported and we should continue to do that.
Does the minister have a sense of disappointment that so many of his own back benchers do not seem to have accepted that point, because they advocate the retention of accident and emergency services? If he cannot persuade them, how can he persuade the people of Scotland?
I am disappointed in that contribution from Shona Robison. It is entirely appropriate that anyone who responds to a consultation should make points as they see fit. The point at issue between her party and the Executive parties is not the detail of individual cases; it is the principle of how we take forward the health service and provide health care throughout Scotland. When we debated "Delivering for Health" in October 2005, Shona Robison agreed with the principle laid out by Professor Kerr of the separation of scheduled and unscheduled care, but we could not have deduced that from her contribution this afternoon, or those of the other members of her party.
On unscheduled care services, Kerr said:
"We believe that current configurations do not appropriately match supply with demand and that highly-trained consultants should focus more on true emergencies, based in well-staffed and resourced departments. … ‘Routine' injuries and ailments will be dealt with"
elsewhere. That is precisely what underlies the proposals that we have endorsed where networks of community casualty units can take the majority of cases that currently go to A and E and deal with them as locally as possible. Under recently approved plans, community casualty units will be established in places where emergency services are not currently provided. That is precisely the direction in which we should move. We will allow emergency specialists to concentrate on dealing with complex cases by focusing their resources on those cases.
To make a distinction in service delivery by claiming that emergency services are somehow not specialist is to fail to understand the medicine of modern emergency care. The life-saving end of modern emergency care is indeed highly specialist—
Will the minister give way?
I need to make further progress.
By removing perhaps two thirds of the cases that currently present at A and E and dealing with them as minor injuries and illnesses in community casualty units, we can allow for precisely that level of specialisation that is required in modern emergency medicine. Such a change will not only improve productivity and reduce waiting times in unscheduled care and the treatment of minor injuries, but support quality treatment for the most urgent and life-threatening cases.
Our clear proposition is that the status quo is not sustainable or desirable. That does not mean that every proposal for change will automatically be supported. Every proposal must be seen to be, and be shown to be, in agreement with the principles of the Kerr report. That is what we expect and will continue to deliver.
In response to Nanette Milne, I point out that the relationship between the provision of acute beds and the provision of health services is changing, and that the basis for such change is also laid out in the Kerr report. The number of beds in surgical specialties has indeed gone down, but that has happened because more and more people are being treated as day cases. The proportion of day-case surgery has risen from 57 per cent 10 years ago to 66 per cent today. We welcome that development, which we think is the right direction of travel, and we want to increase that proportion further. We want more and more people to be able to be treated in out-patient departments and in primary care so that they avoid the need for admission to hospital. We believe that, in so doing, we are improving the quality of care as well as delivering care more locally than was the case in the past.
Several members raised issues about the workforce. It is important to say that we are planning and expanding our workforce of nurses and GPs while taking predicted rates of attrition into account. We are ensuring that we provide mechanisms to allow that attrition to be compensated for in future. Workforce planning is a sophisticated process that is now being done in more detail and with more effectiveness than ever before. For both the medical and nursing professions, such planning will provide real benefits in the years ahead.
Will the minister take an intervention?
I am sorry, but the minister is in his last minute.
On community nursing, I can confirm that that will be piloted before it is rolled out further.
Mention was made of breastfeeding as an important policy. We completely support that policy and we will continue to support and develop it. I hope that we will continue to see progress on that.
In response to the issues that were raised about hospitals such as that in Glencoe, I can give an assurance that ministers will continue to expect detailed consideration of proposals before approval of any change is given. That will continue to be part of any decision-making process.
The fundamental argument in the motion is that we should celebrate our successes. There are challenges in achieving the shift towards a more locally delivered health service but, as we have heard from a number of members, there are already successes on which we wish to build. I call on Parliament to support that proposition, and to recognise that change is right and that the direction of travel in which we have set out will deliver the best outcomes for patients. As Euan Robson said, it is about outcomes. We have seen good progress in the recent past and want to see further progress in the period ahead.