Health Boards (Membership and Elections) (Scotland) Bill: Stage 1
Good morning. The first item of business is a debate on motion S3M-3162, in the name of Nicola Sturgeon, on the Health Boards (Membership and Elections) (Scotland) Bill. I remind members that the Presiding Officers will no longer give a warning when a member has one minute remaining to speak. However, we have a little flexibility this morning to allow members to take interventions. We will monitor the situation as the debate goes on.
I am pleased to open the debate on the general principles of the Health Boards (Membership and Elections) (Scotland) Bill. Before I get into the substance of my speech, I offer my thanks to the many organisations and individuals who took the time to participate in our consultation. I also offer my thanks to Christine Grahame and the Health and Sport Committee, as well as to colleagues on the Finance Committee and the Subordinate Legislation Committee, for their robust scrutiny of our proposals. I have been encouraged by the support for the principles of the bill from the many individuals to whom I have spoken the length and breadth of the country, the many patient representative groups that responded to the consultation, and organisations such as Unite and Unison, which are two of Scotland's biggest trade unions.
At the outset, it is important to set the bill firmly in context. Members will recall that "Better Health, Better Care: Action Plan" set out our vision of a mutual national health service in which ownership and decision making are shared with the public and the staff who work in the service. The bill, together with our proposals to strengthen existing public engagement processes, our plans for a participation standard and ownership report, and our intention to introduce a new patients' rights bill, is designed to bring to life the concept of mutuality.
Many people in all parts of Scotland believe—rightly, I think—that there is a real democratic deficit in the operation of our health boards. Too often, the public feel shut out of the big decisions that health boards take daily and which account for significant sums of public money. Sometimes, that exclusion from the decision-making process leads to deep-seated alienation from the decisions that are reached. There can surely be no better illustration of that than the decisions, which the present Government later overturned, to close the accident and emergency units in Ayr and Monklands hospitals.
The bill's clear objective, therefore, is to allow the public voice to be heard and listened to at the heart of the decision-making process. That is how it should be: whether in cities with their challenges of health inequalities, or in rural areas that face the challenges of remoteness and rurality, people have strong views and, more important, they have real-life experience of what works and does not work. Therefore, people should be involved in consideration of developments in their areas and in the decisions about how resources are spent to best meet those challenges.
Of course, as I and others have said on many occasions, people being directly elected to health boards will not take away the need for difficult decisions, but I believe strongly that having elected members on health boards will enhance and improve the quality of decision making in the NHS. In my view—a view that, if anything, has been strengthened in the past few months—when people are involved in decision making, and when they understand and become persuaded of the reasons for change, they are far more likely to be drivers of change than they are to be barriers to it. Problems arise when people feel excluded from the process and are denied a say in decisions.
The Government is committed to democratisation of our NHS boards. We believe that democracy is a good thing and that opening up NHS boards to the public through elections will deliver better decision making and, ultimately, even better services than those we already enjoy.
However, I realise that many people, inside and outside Parliament, remain unconvinced. As well as powerful positive contributions from bodies such as Unison and Voluntary Health Scotland, the Health and Sport Committee heard a range of concerns from organisations such the British Medical Association. Those organisations' voices are respected and their views should be listened to. Many of the concerns that have been voiced about direct elections have been addressed in the bill. For example, some people are concerned that the flip-side of local democracy could be a postcode lottery of provision. It is precisely to allay that concern that the bill proposes no change whatever to ministerial powers of direction or to the clear line of accountability that exists from NHS boards, through me, to Parliament.
Although I accept the need for accountability to the health minister, is not there something inconsistent about having directly elected members who can be dismissed by that minister? I make that point despite my support for the general principles of the bill.
The health minister's power to dismiss members of health boards already exists. As Malcolm Chisholm will be aware, I have been unable to uncover any example of that power being used. The chances of its being used in the future will remain very remote.
Malcolm Chisholm is correct that, with directly elected members, any health minister seeking to use the power would have to have the strongest possible reasons for dismissal because the decision would be subject to the closest scrutiny. However, it is right to retain the status quo because all members of health boards should be treated in the same way in that regard.
The Subordinate Legislation Committee's concern was about the conflict whereby ministers will have the power to dismiss a person who had been democratically elected to a board.
I may be wrong, but I predict that amendments will be lodged on the issue at stages 2 and 3, so I am sure that we will have more discussion. I have made clear my views in the Health and Sport Committee and this morning. Ultimately, however, the decision is for Parliament.
As I said, many of the concerns about direct elections are addressed in the bill, but some of the concerns are speculative. That does not necessarily mean that they are wrong: it simply means that questions such as whether people will want to stand or whether single-issue candidates will dominate can be answered only through experience.
Will the cabinet secretary give way?
I want to make progress. I will take an intervention later, if I have time.
That is why we have responded to the significant number of people who said that we should pilot elections before deciding whether to introduce them throughout Scotland. That is the right approach. It is also right that Parliament, and not just the Government of the day, will decide whether to roll out the proposals throughout Scotland, and that it should do so only after a full and independent evaluation of the pilots. The bill as it stands will put Parliament in the driving seat, but in response to the Health and Sport Committee's stage 1 report, I have agreed certain changes that will further strengthen Parliament's hand. Earlier this week, I wrote to that committee and to Opposition spokespersons confirming that I will seek to amend the bill's long title at stage 2 to make it clear that the bill is concerned primarily with pilots. I also confirmed that I will introduce an amendment to make the decision on roll-out subject to the super-affirmative procedure.
I will outline the proposed approach to the pilots. My view is that we should pilot the elections in two health board areas that are representative of Scotland's population and geographical diversity. We must also test the pilots over a reasonable period. The bill provides for an evaluation of the impact of elections to be placed before Parliament not more than five years after the pilots commence. The bill proposes that a majority of a board's members must consist of directly elected members and locally elected councillors. As an aside, it is worth noting that, for the first time ever, the bill will give statutory underpinning to local authority membership of boards. That is important, because the role of local authority members is vital to ensure seamless delivery of health and care services throughout an area. Our move to recognise in statute the important role of local authority members reinforces our commitment to building a strong partnership between the NHS and Scottish local authorities.
On the method of election, we propose the single transferable vote. In discussion with electoral administrators, we have agreed that we should use the same STV system that is used in local government elections. For the pilots, we propose an all-postal ballot, which is in line with the approach for national park board elections. We also propose to extend the voting franchise to include 16 and 17-year-olds. That is the right thing to do, because we want direct elections to health boards to include as many users of the NHS as possible. The measure is an important way in which to introduce young people to the democratic process as they reach adulthood, because it concerns a public service of which they will already have considerable experience.
A key focus of the discussions that have taken place on the bill—especially in the Finance Committee, which is not surprising—has been the costs of holding pilot elections. We have estimated those costs at £2.86 million. The figure is based on the costs of holding an all-postal ballot covering two health board areas that represent about 20 per cent of Scotland's population. It would not be fair to expect health boards to bear the burden of those costs, so I have given a commitment that they will be met from central resources and not from health board budgets.
Before I draw my remarks to a close, I want to deal with the suggestion that was made during the consultation and in committee evidence-taking sessions that the democratic deficit in the NHS that I have described this morning could be dealt with through approaches other than direct elections. For example, some people have suggested that we should simply strengthen existing methods of engagement. I agree that we should do that; the consultation made clear that elected health boards would be only one part of the process.
I am committed to improving public engagement and involvement with health boards. All boards encourage community and public involvement, and will continue to do so. They also have a statutory duty to show year on year how they are improving their engagement with the public. We continue to strengthen the links between communities and the NHS through further work with bodies such as community health partnerships. I have already spoken about initiatives such as the development of a participation standard. Although all that is important, none of it is a substitute for direct elections to health boards. If we are truly to enhance public engagement and involvement, such measures and initiatives should go hand in hand with direct elections.
Others, including the Health and Sport Committee, suggested that we pilot alternative approaches to enhancing public involvement, and that we do so in parallel with the direct elections pilots. I agree that that would be a useful exercise. In advance of stage 3, I will introduce plans to conduct other forms of pilot, which will take place concurrently with the direct elections pilot in board areas that are not included in that pilot. That will allow Parliament to assess the impact of direct elections not just on their own merits, but against other potential methods of increasing public engagement and involvement. We should not lose sight of the fact that all the methods that we are discussing are simply means to an end, which is better public engagement and involvement.
I have made commitments both to the committee in writing and to Opposition spokespersons on the place of Parliament in the decision about roll-out of elections and on alternative pilots. Given those commitments, which I have repeated in Parliament today, some members may regard Ross Finnie's amendment as superfluous. However, that is not a reason not to support it; I advise Parliament that SNP members will support the amendment at decision time this evening.
In conclusion, I have been encouraged by the level of interest in, and engagement with, our proposals across the country. What is proposed will undoubtedly result in a real change in the make-up of our health boards—a real shift in the balance of power. It will ensure locally mandated representation on health boards, while retaining the strengths of those who currently sit around the table on boards. Direct elections will represent a significant step towards ensuring that the public voice is heard and, more important, that it is listened to at the heart of NHS decision making.
I move,
That the Parliament agrees to the general principles of the Health Boards (Membership and Elections) (Scotland) Bill.
I have difficulty recalling an occasion in the nearly 10 years that I have spent in Parliament, on which dealing with the principles of a bill, as set out in that bill, has been more difficult. At first blush, it is clear from the long title that—as the cabinet secretary cogently put it—the bill is about ensuring that direct elections are part and parcel of our system, and about the method by which such elections will take place. Curiously, however, when we reach sections 4 and 5 of the bill, we find that there is conditionality; perfectly reasonably, the bill specifies that Parliament will have powers. Do not get me wrong—I do not object to that. The cabinet secretary has very properly provided for Parliament to consider the matter before it decides whether to proceed. However, today we are being asked to vote on the general principles of the bill, so we need to ask ourselves what we are doing or pre-empting.
I appreciate that the rules of Parliament make it clear that in a stage 1 debate one should not seek to qualify the general principles of a bill. I have lodged my amendment, on which I spent a considerable amount of time—I am grateful to the chamber desk for assisting me with its drafting—simply to note and to make clear on the public record that we are not pre-empting the parliamentary decision for which the bill provides. No one is arguing that we should; nevertheless, the Liberal Democrats think that it is important for the amendment to be part of the resolution that Parliament approves.
In addition to being the Liberal Democrat spokesperson on health, I have the benefit of being a member of the Health and Sport Committee. I make my remarks as a Liberal Democrat spokesperson—I have no doubt that Christine Grahame will address in detail the issues that were raised with the committee. However, with the benefit of hindsight, I have come to the conclusion that the bill may not have started at entirely the right place. As the cabinet secretary indicated, there is considerable disquiet about the way in which health boards are discharging their functions, although that is not spread evenly across health boards or across Scotland. There is a view that boards are not responsive and that board members are not clear about what they should do to engage with the public.
The evidence that was given to the Health and Sport Committee indicated that there is great disparity in how boards function—I am bound to say that I gained the impression that the corporate governance of our health boards is very vague. As each health board witness came before us, we did not get the impression that executive directors are clear about their functions or that non-executive directors, led by the chair, are clear about theirs. Even at this late stage, I am concerned, with the best will in the world, that bolting on a new system of non-executive directors will not necessarily work when we have given little attention to examining how the actual board structure does and does not function. I am not, however, suggesting that we hold a three-year inquiry into how health boards operate.
No.
Not even I would suggest that. However, if we are properly to evaluate the pilots' achievements, it would be helpful for us to have greater clarity about how boards discharge their functions and about the roles that executive and non-executive directors see themselves playing. The evidence that the committee took on that was very unclear.
The cabinet secretary posits that boards got it wrong on Monklands and Ayr. I do not necessarily agree, but if they did, how did that happen? How did allegedly sane and rational people who had been selected for office and who knew and understood their functions apparently so misrepresent the public whom they were supposed to represent? Even board members who are not directly elected have functions to discharge, but how they should do so is unclear.
I turn to the other provisions of the bill. I am grateful to the cabinet secretary for her public statements this morning and for the letters that she has written to the convener and members of the Health and Sport Committee and to the Subordinate Legislation Committee. There are two critical matters, apart from those that are addressed in my amendment. As the cabinet secretary said, it is now in her mind to amend the bill's long title. Members will understand that that adds to my difficulties this morning because, given that the long title is in general terms the basis upon which one defines the principles of a bill, as soon as the cabinet secretary lodges that amendment she will by definition to some extent have changed the principles of the bill. She will not have changed the whole principle of the bill, but she will have qualified its principles.
I know that Ross Finnie knows this, but he should acknowledge that although I will lodge an amendment it will be up to Parliament to decide whether it passes it.
I am aware of that, but I am also aware of the persuasive qualities of the cabinet secretary when she lodges amendments. I perhaps overestimated the effect of that, but I certainly had it in mind when I made that statement with some confidence.
The second important issue, which was a key recommendation in paragraph 123 of the committee's report, is what we now rather inelegantly call the super-affirmative procedure. I am not sure that anyone who is of a legal persuasion will be terribly taken with that term, but it is nonetheless important because it means that if we come to the pilot stages—no matter what they are and no matter their form and shape—not only will the affirmative procedure be used, but no decision will be taken by Parliament without all the evidence being produced and published and without its being scrutinised by Parliament before the decision is taken.
The Liberal Democrat construct of introducing a reasoned amendment to point out that what is in the bill itself contains a degree of conditionality, and the two important undertakings that the cabinet secretary has given in her letters mean that she can be assured of our support. I am not entirely sure that that will give the Government a majority on the bill, but it will be terribly close when we come to the vote.
It is important that we now give thought to how we will test the various propositions and address the concerns of those who genuinely wonder, irrespective of the current state of the board structures, how to get a decent electoral system in place and how it will work. Although I and the Liberal Democrats are keen to extend the franchise to 16-year-olds, we know from the evidence to the committee that a number of disturbing issues that were raised have to be addressed if that is to be carried out properly. It is clear that there are issues relating to voter identification and the need to produce, in the lead- up to the process, information on how to maintain an electoral roll that does not interfere with the privacy of minors but which at the same time allows them to be scrutinised and examined in exactly the same way and on the same basis as any other elector. I hope that there will be wider discussion on what the alternatives might be and on the other propositions that the cabinet secretary has said she is prepared to bring forward as part and parcel of the process.
I and the Liberal Democrats share with the cabinet secretary the view that the objective must be to have health boards that operate efficiently and which appear definitively and definitely to understand their function and that, in so far as they are the keepers of the public purse at a lower level than Cabinet level, they also understand the importance of the input of the public. It was a little disappointing that, although during the committee's evidence sessions a number of the health boards spoke a lot about how there could be wider engagement with the public, they always seemed to talk about it being below board level. I am not against that, as such engagement plays an important part in improving public engagement, but, given that the fundamental thrust of the criticism from parliamentarians across parties related to how the boards function, it was a little disappointing that so many of the chairs spent so much time saying, "If we deal with engagement below board level, that will be okay." I say very gently to those chairs, "No, it won't." I would be happier if, as a fundamental starting point for the exercise, I knew why some of the corporate governance appears on the face of it to be more dysfunctional in some boards than in others. That is a crucial point.
As I say, I am happy if we have elections to health boards, but given that Parliament is much exercised by trying to improve the quality of care in our communities, and that we are trying to get rid of the existing barriers between local government and health boards, I remain to be convinced that creating directly elected health boards with a separate mandate from those who are elected to local government to represent the wider population as a whole, and having those two separate bodies will contribute to greater co-operation and collaboration in our health and care partnerships. That is a matter on which I and the Liberal Democrats have still to be persuaded, but we now have the possibility to move to stages 2 and 3, when such matters can be further examined.
I move amendment S3M-3162.1, to insert at end:
"but, in so doing, noting the terms of the Health and Sport Committee's Stage 1 report, calls on the Scottish Government to bring forward, ahead of Stage 3, firm proposals for the piloting of a variety of alternative schemes to improve public participation and shares the committee's view that such agreement to the general principles should not be taken to pre-empt any decision that the Parliament may later be asked to take on the rolling out of direct elections to health boards nationwide."
I ask Christine Grahame to speak on behalf of the Health and Sport Committee. You have around seven minutes.
That constrains me—not a position in which I usually find myself, Presiding Officer.
I thank Ross Finnie for his thoughtful speech and for his amendment, which has meant that my speaking time has been cut by four minutes. I do not find that an unhappy position to be in because I think that we will be in groundhog day to some extent during the debate.
It was not deliberate.
I am delighted, in any case.
I also thank, on behalf of the committee, all the witnesses who gave written evidence. Everyone knows that volume 2 of the report itemises and lists a substantial cross-section of the submissions. I thank those who were called and came to the committee to supplement their written evidence with oral evidence. Although I suspect that there is still a great deal of work for the committee to do at stage 2, I thank members for delivering a unanimous report—it is always commendable when committees achieve that—following thorough debate, which was mixed with the usual humour for which we are known. We are, indeed, a venerable and humorous committee.
I also acknowledge Bill Butler, who is in the chamber and who did so much with his member's bill to progress the matter. The member's bill process is the way in which many issues come before Parliament, so I hope that more members' bills get a breath of fresh air in Parliament and that we move on to pass them as legislation.
The committee recognises that we cannot stay where we are. As Ross Finnie and others have said, in relation to the closure of accident and emergency departments and the closure of community hospitals in areas that I represent, such as Jedburgh and Coldstream, it took people aback when anonymous figures—the public had no idea who they were—appeared at public meetings after alleged consultation, which is another issue, and told the meetings that various services were to close. It was obvious that we had hit on a democratic deficit. Perhaps a function of Parliament over the nine years of its existence has been to ensure not only that we are open to scrutiny but that when it comes to local authorities, housing associations and health boards people are much more engaged and more aware of their rights. That is as it should be.
We all know that not every local community will get what it wants, even if we have directly elected health boards, but we want them to feel that they have had a fair crack of the whip and, as Ross Finnie said, are engaged at all levels: not only at lower levels but at health board level.
I now move on to some of the key issues that the committee raised—I had better talk more slowly. There have been responses on many of the issues. I am grateful to the cabinet secretary for responding with such alacrity in her letter of 12 January to the committee, but one or two issues still remain open. We will poke at those at stage 2 and I remind the committee that, if we wish, we can call witnesses back at that stage to discuss amendments.
Paragraphs 22, 33 and 34 are key ones in the report. The recommendations in those paragraphs are about improving public consultation by health boards. We do not believe that public participation in, and the accountability of, many health boards has been adequate, although we know that the situation has improved. Evidence also suggests that efforts to promote diversity in health boards are failing. That point relates to evidence that we received about disabled people. There is also concern that if we have direct elections people who live in remote areas will have difficulty putting themselves forward for election—I am looking at Jamie Stone in respect of that point. If pilots go ahead, a rigorous evaluation of their impact on the diversity of health boards and on the equalities impacts of their policies should be made. The cabinet secretary has agreed to that recommendation.
The committee was not convinced that elections are necessarily the most effective way of achieving better engagement and accountability, although it agreed that they have the potential to do so. It did not see elections as necessarily excluding other initiatives such as public participation forums. The cabinet secretary agreed to that in her letter.
The bill will not change health boards' accountability to ministers; the committee considered that to be the correct approach. However, Malcolm Chisholm raised the concern that the public might not appreciate the subtle difference between elected members' local accountability on delivery and ministers' national accountability on policy, which could lead to disillusionment. We suggested that, if the elections proceed, there should be a public information campaign so that people understand that the board is accountable to the cabinet secretary for policy delivery but that accountability for practical delivery on the ground would rest with health boards. It is a neat distinction, but there are going to be some difficulties if expectations are not always met, particularly if several single-issue members are elected to health boards; there could be tensions there.
In paragraphs 97 and 98 of our report, the committee supports the ideas of parallel pilots alongside those that are set out in the bill, and of comparing health board elections with other initiatives to improve public engagement. I have put a tick next to that point as well—the cabinet secretary has agreed to it.
The committee drew attention to uncertainty about the total costs of nationwide direct elections. The committee endorsed the Finance Committee's call for a reassessment of roll-out costs in the light of a proper assessment of the pilot costs. Those recommendations are in paragraphs 109 and 111 of our report—there is a tick next to them because the cabinet secretary has also addressed that point.
The committee called for tighter parliamentary scrutiny of any decision to roll out health board elections or to abandon the pilots than is provided for in the bill. That involves a decision of principle. There is also a tick next to those paragraphs, and we are now going for the grand design and new plan with the super-affirmative procedure. We are all going to read the book on that—I hope that someone has produced one.
Overall, the committee did not believe that there was an overwhelming case for health board elections, but there was broad support for piloting the proposal. The committee therefore supports the introduction of pilots but stresses that that should not be taken as a decision to support health board elections per se. Notwithstanding some issues around amending the long title, the cabinet secretary has addressed that, so I have ticked it.
However, some of our recommendations do not have ticks. We said that personal identifiers should be required for all postal ballots and health board elections. The cabinet secretary is not planning to do that.
In addition, the committee did not consider the proposal for a private young person's register to be a recognised part of the democratic process. I know that I said I would not talk for my full time, but I will read out what the committee report said.
"The experience of the Scottish general elections in May 2007 shows that the robustness of any new elections introduced in Scotland will rightly come under serious scrutiny. Whilst the Committee recognises that there would be significant cost and logistical implications, the Committee recommend that the Scottish Government reconsider using personal identifiers for postal votes in health board elections. If the cost and logistical implications are too great to be overcome, the Scottish Government may also have to reconsider holding an all-postal ballot."
That is a serious issue in the light of the public's recent experience, and the minister might hit a bit of a brick wall with that one.
I apologise to members in the chamber, but I make them and the Presiding Officer aware that I need to leave the chamber to attend another engagement. I do not mean any discourtesy, and I hope to be back to hear the closing speeches.
I welcome the debate as an opportunity to contribute to discussions on participation in our health services and their accountability. Like the cabinet secretary and the convener of the Health and Sport Committee, I thank those who contributed to the consultation. I also thank the committee for its helpful report and the cabinet secretary for the letter that was circulated earlier this week.
As we said in our manifesto for the 2007 Scottish Parliament elections, Labour Party policy is to support pilots for direct elections, so today we will support the general principles of the bill. It is worth putting on the record that Labour has a strong record in government of increasing the accountability of health boards to their communities. Ross Finnie raised a number of interesting issues around that.
We fully support community engagement with the NHS. Allowing the public's voice to be heard, listened to and taken seriously must be at the heart of health boards' decision-making processes. It is vital that we ensure that local communities are well served.
Labour implemented significant measures in the National Health Service Reform (Scotland) Act 2004. That legislation was designed to improve accountability and public involvement, and it made considerable progress towards that goal. The introduction of a single management tier through the abolition of the trust system simplified avenues of accountability, and community health partnerships were a step in the right direction for public involvement by providing parents, carers and the public with an opportunity to participate more fully in health boards' decision-making processes.
Unison Scotland has highlighted the point that there is widespread support among patients groups for the bill's principles. I am well aware of the strength of feeling in local communities about what they see as their local services.
However, public engagement must not just be about the major and often controversial issues involving hospitals. Such engagement must become the norm for the whole range of health services, and it must reach beyond the affluent and the articulate to include those who need support and advocacy to get their views heard. I am sure that we will return to those issues during discussions on the proposed patients' rights bill.
Although I said that we will support the bill's principles, we have serious concerns about the way in which the bill has been drafted. We recognise that the cabinet secretary has accepted that there are a number of areas in which amendments need to be made at stage 2. We will look at what more needs to be done. We must explore the concerns that have been raised and make constructive suggestions about the further work that could be done to ensure that the proposed pilot schemes are a valuable endeavour.
A number of criticisms have been made, including by the British Medical Association, that there is no evidence to show that directly elected health boards are effective and that the bill might be overpromising on public engagement. Unison has pointed out that directly elected health boards are not simply a substitute for other forms of public engagement.
It is also important that the cabinet secretary fully considers the concerns highlighted by the Health and Sport Committee. I emphasise one point that the committee raised: the pilots must be robust and fully assessed, and alternatives must be examined before roll-out is considered. We have already seen some important movement on that. The pilots must also be properly funded, and front-line patient care must be protected.
We should try to assess different models before any decision is taken on implementing a specific model. In her letter of 12 January, the cabinet secretary offered an undertaking
"to bring forward details of non statutory pilot schemes that will run concurrently with elections".
She has committed to doing that before stage 3; I welcome that commitment and look forward to examining those details in due course.
The financial memorandum assumes that two identical pilots will be run in different areas, at a cost of £2.86 million. However, concern has been raised that that figure does not include the cost of the remuneration of elected members, the cost of the evaluation study, the cost associated with extending the franchise, and the cost of public awareness materials. I hope that the cabinet secretary will commit to looking at those areas.
The cabinet secretary has said that she will make clear proposals on the timetable for the additional public participation pilots. Now that that commitment has been given, the full costs associated with those proposals and the costs of the two original pilots need to be brought together clearly and concisely.
In its report, the committee says that it
"does not believe that there is sufficient certainty about the total costs of health board elections were they to be rolled out nationwide".
I am concerned by the growth in the estimates for a national roll-out of health board elections; we must continue to look at that area, which is of serious concern. When the bill was introduced, the Government gave an initial figure of £13 million, but that had risen to more than £16 million by October last year. Just this week, it seems that the estimated costs have now risen to more than £20 million. On the Government's uncertainty, I echo the view of the Health and Sport Committee and the Finance Committee that the evaluation of the pilots must include a full assessment of all costs.
I am aware that I do not have a great deal of time left, but I wish to put on record serious concerns about the proposal to extend the franchise for the elections to 16 and 17-year-olds. Before someone digs out a previous quotation from me on this subject, I should say that it is fairly well known that, within the ranks of the Labour Party, I am one of those who are more sympathetic than others to the notion of 16 and 17-year-olds having the franchise. However, I do not believe that this bill provides us with the right mechanism to test that idea, given the concerns that have been rightly raised by the committee about the private nature of the register. I do not want the issue of the extension of the franchise to get in the way of our ability to consider properly the other issues around public engagement. I therefore ask the cabinet secretary to think again about the issue and perhaps to engage in further discussions before pushing forward with the proposal.
There is no doubt that there are serious issues that must be addressed around the implementation of the pilots. I draw the chamber's attention to the salient point that was made by Malcolm Chisholm, and restate the fact that there are grave concerns about bringing in a piece of legislation that would give ministers the power to remove someone who had been directly elected by the public. We need to think hard and seriously before passing a bill that has that power at its core.
Improving public engagement and involvement in the NHS remains a cornerstone of Labour's health policy. We will continue to scrutinise the proposals closely as the bill proceeds, and we welcome Ross Finnie's amendment. As the cabinet secretary said—and as Ross Finnie perhaps recognises—the amendment is not strictly necessary, but we believe that it sends a strong signal, which is why we will support it.
When I first approached the bill, I thought that its progress through the Health and Sport Committee and the chamber would be straightforward and that it would simply be passed with a few tweaks and amendments. However, the fact is that the bill has not exactly been wholly welcomed or endorsed by those who responded to the call for evidence. I can also confirm that, although I have been active in the political world in the Highlands and Islands for some time, I have never been asked to try to bring about health board elections. Further, when I asked my Labour and Liberal colleagues whether anyone in the Highlands had asked them to deliver health board elections, they said that that no one had.
Ross Finnie made a good point about the governance of health boards: we should not assume that all health boards are bad at consulting. Although I have my differences with Highland NHS Board, I can confirm that it consults on various issues. Thousands of people participated in the consultations on maternity services in Caithness and the proposed reduction in services at the Belford hospital in Fort William—indeed, one health board official returned to Inverness saying that he was traumatised by his experiences in Caithness. There was engagement and the health board listened to the public, which resulted in the retention of the services that we fought for.
Although we will support the bill at stage 1 today, that should not be taken as a guarantee of our support at stage 3. Of the 54 responses to the Health and Sport Committee, 15, or 27 per cent, were in favour of health board elections, and 19 were against. If we take out the 20 responses that expressed no preference, that still means that only 44 per cent were in favour while 56 per cent were against. Further, of the 19 responses that were against the proposal, only five were from NHS bodies, so we should not assume that it is only the NHS that is against elections to health boards—civic Scotland does not support the bill either. In any democratic system, that lack of support cannot be ignored.
There was more favourable support for the pilots, however, with 19 responses in favour and two against. On that basis, we will support the Liberal Democrats' amendment. I am not entirely convinced that it is necessary, but I feel that putting a greater focus on the pilots and having something about them in writing would be helpful.
The Scottish Conservatives welcome the commitment of the Cabinet Secretary for Health and Wellbeing to reconsider the issue of restricted NHS posts, to make use of the super-affirmative procedure, which none of us seemed to have heard of until now—
Not so.
Those on the Subordinate Legislation Committee are, of course, familiar with it.
We also welcome the cabinet secretary's commitment to ensure that thorough and independent evaluations of the pilots are conducted, to change the long title of the bill to reflect the emphasis on pilots, and
"to bring forward details of non statutory pilot schemes that will run concurrently with elections in advance of stage 3."
Like Cathy Jamieson, we are concerned that the cost of the full roll-out of the elections has risen from £13 million to £16 million—and we are still only at stage 1 of the bill. With the use of personal identifiers, we are looking at a cost of £20 million. Our main concern is that those funds will come from front-line NHS services.
I ask that more attention be paid to the issue of the NHS Highland electoral ward, which would cover more than 40 per cent of Scotland's landmass and would include 30 islands. Its population centre is Inverness, which makes it likely that candidates will come from Inverness and the surrounding area. Although the salary will be the same for each member, members from further afield will have to pay considerable travel costs. More important, some of them will have to make a much greater time commitment than others. I give, as an example, the situation that an elected member from Tiree would find themselves in. The ferry takes three hours and 40 minutes to get to Oban from Tiree, and there would be a further three-hour journey by car, or a whole day's journey by public transport, to get to Inverness. The shortest time that it would take a member from Tiree to get to Inverness and back would be six hours and 40 minutes each way, which means that they would need to allow for a day's travel on either side of a meeting, with possibly two overnight stays. Anyone with a full-time or part-time job would find it impossible to make that commitment. A further problem is the issue of leafleting the NHS Highland area. How could a candidate afford to pay for the distribution of a leaflet across that huge area? All of that means that only those who are both time and money rich will stand.
I appreciate that not all meetings will be in Inverness, but, as it is the main population centre, it is likely that most of them will be.
Is the member therefore not in favour of people who live in Tiree being appointed as non-executive members? They have to pay the same expenses and face the same travel time as would someone from Tiree who was elected to the board.
We are not discussing that issue. Anyway, there is no doubt that, before an appointment is made, there is a discussion about whether the person is able to commit the time that is required. The point remains that NHS Highland has the largest health board area in Scotland.
I know that, in the Health and Sport Committee, Dr McKee has raised concerns about the potential politicisation of health boards, which is something that we do not want. However, it is likely that political parties will put forward candidates for the elections, given that they have the necessary organisation and experience.
Does the member agree that the fact that the weight of the population in the Highlands and Islands is around Inverness will skew the result and alter candidates' chances?
That is a possibility, and people in Caithness have been concerned for years about the fact that they do not have a representative on NHS Highland.
Although election expenses are to be determined by regulation, I presume that that will involve the maximum spend rather than assistance with election addresses and so on. I would like that to be clarified.
We are concerned that independent scrutiny panels, public partnership forums, health councils and other fairly new initiatives have not been given sufficient time to bed in prior to the introduction of the bill. We also remain concerned about ministers' power to remove elected members from health boards.
However, my main point of concern involves the Government's capacity to overturn health boards' decisions. Its reversal of the plan to remove accident and emergency services from Ayr and Monklands hospitals was welcomed by many across Scotland. However, how difficult would it be for the Government to overturn a decision of an elected health board, following the intervention of an independent scrutiny panel? Would a minister take the advice of the directly elected health board or that of the independent scrutiny panel? I look forward to that issue being clarified later today.
We now move to the open debate. We have some time in hand, so members may speak for up to seven and a half minutes if they so wish.
Presiding Officer, you were given notice of my delay in being present at the start of the debate. Unfortunately, I missed the cabinet secretary's opening speech due to Network Rail arranging a signal failure that affected my train journey this morning. As a regular train user, you will no doubt appreciate that difficulty.
Naturally, we are very proud of our national health service, which holds a unique place in the minds of people throughout Scotland. The NHS is a public service that people strongly believe belongs to them rather than to a particular Government at any given time. People believe that the service exists for the collective benefit of everyone in our society. I am always reassured by the public's considerable depth of good will towards the staff who work in our NHS—which does not always apply to those who work in other public services—although that good will towards NHS staff often stops at the door of the health board.
In dealing with NHS issues, I am always aware of the fact that people have a level of emotional attachment to the NHS, particularly the local elements of the service. That emotional attachment often becomes extremely evident when health boards consider closing or reconfiguring local health services, as happened in the Forth Valley NHS Board area—which covers my constituency—and the Lanarkshire NHS Board area. Despite the public meetings and other events that took place, there was a genuine public perception that, before proposals even went out to consultation, the health boards had already decided how they would reconfigure services, which services would be closed and which hospitals would no longer provide particular services.
To some extent, people have become so cynical that they often feel that the consultation process is nothing more than a window-dressing exercise. We could get into a debate about whether that is true, but I believe that people have a genuine grievance. The issue is well illustrated by the thousands who turned out for the public consultation events that were organised by Lanarkshire NHS Board. Despite overwhelming opposition within that community to the proposals to close or reconfigure services, the board ignored the outcome of the consultation and tried to drive ahead with the proposed changes. In my view, such experiences undermine the public's confidence that health boards listen to the communities that—I emphasise this point—they exist to serve.
I believe that having a directly elected element on our health boards provides the potential to create a level of openness and transparency in how our NHS operates that is missing. It is also worth reflecting on the fact that our NHS boards are responsible for spending some £8 billion-worth of taxpayers' money every year. In my view, such a large budget justifies greater democratisation in how it is used.
Like other committee members, and other members who are present today, I felt that it came as no surprise that every health board that made a submission in response to the committee's call for evidence on the bill opposed the idea of having any element of directly elected representation on health boards. Unison summed up the matter well:
"Opposition to the Bill in the main comes from the health establishment that believes health is too complex for mere mortals to comprehend. This reflects the ‘we know best' top down health management culture that needs to be changed."
One health board—Lothian NHS Board—that gave oral evidence to the committee went so far as to suggest that it had actually consulted patient groups and other interested parties before submitting its views to the committee. However, when we asked for evidence of that, it became clear that that was not the case whatsoever.
If there is one lesson that comes from our evidence-taking sessions, it is that some health boards—I think, sadly, the majority—seem to have forgotten that they exist to serve the public interest rather than their own interests. I believe that one result of having a directly elected element on our health boards is that it would help to refocus minds on that.
An extremely important point is that, once the pilots are up and running, health boards must not interpret the inclusion of an elected element as in some way removing the need to continue to engage with and consult the communities that they exist to serve. Like Cathy Jamieson, I agree that having directly elected health board members should complement on-going engagement with the communities that health boards exist to serve.
I turn to a couple of issues that were raised by the committee in its stage 1 report. The cabinet secretary's response that she will provide details of other types of pilots before stage 3 consideration of the bill is extremely useful. I think that it would be worth running other types of pilots to see what value can be gained from them.
Another issue concerns restricted posts within the health service, the holders of which might not be entitled to stand for election to the health board. As currently drafted, new schedule 1A, which the bill would insert into the National Health Service (Scotland) Act 1978, could lead to a lack of consistency in how boards designate certain post holders as not being entitled to stand in a health board election. I believe that the amendments that the cabinet secretary plans to lodge at stage 2 will help to address that. It is extremely important that, if we are to have a register of restricted posts—as is the case in local authorities—we have consistency in the way in which that is applied by health boards across the country.
Finally, like others, I am prepared to support the amendment to the motion, although I suspect that it may have been overtaken by events, given the cabinet secretary's response. I hope that other members will be minded to support the general principles of the bill later today.
I congratulate the Cabinet Secretary for Health and Wellbeing on introducing the bill. As Ms Sturgeon and others will be aware, Labour now has a policy of supporting pilots in which 50 per cent plus one—a simple majority—of health boards are directly elected. I am glad to say that I played some part in persuading my party of the efficacy of such a policy position. Although not a betting man, I would venture that the Government's bill will gain support at stage 1, where previous efforts have—inexplicably—failed. That is good news.
I welcome the Health and Sport Committee's stage 1 report and the diligence of all its members, including its excellent convener, Christine Grahame, who made a detailed interrogation of the bill at stage 1. I said that I would refer to Christine Grahame in that fashion.
I have believed for some time that there is strong support across Scottish society for the introduction of direct public elections to Scotland's NHS boards. I also believe that there is a compelling case for greater democracy, accountability and transparency in the decision-making process for local health services. I continue to believe that the best way to achieve greater accountability and transparency is through the introduction of direct public elections.
The bill will significantly increase public involvement in local NHS services by involving people in the planning and delivery of health care services in their communities. Its main aim of introducing more democracy into the operation of health boards does not mean—and I emphasise this point—that I believe that all health board decisions are necessarily wrong and detrimental to local health services. Such a view would be absurd. However, the undeniable problem with the way in which health boards currently operate and reach decisions lies as much in public perception as in the nature of those decisions. To an extent, the anger that some people feel about certain decisions is generated by the manner in which those decisions are seen to be made. They are made in secret, with little or no explanation offered; they are often predetermined; and they often ignore the views of the community and the responses that have been made to the board's consultation process. Many people believe that health board consultations are fake, and that is not a happy situation.
Of course, there is no perfect method for consulting the public on major local health issues, so I do not believe that direct public elections would lead to everyone being happy with every decision that an NHS board makes. However, I contend that decisions made by health boards that have a large element of democratically elected members will have much more credibility than decisions made under the current system.
When reading the evidence given to the Health and Sport Committee, I did not see a convincing explanation of why the make-up of regional NHS boards should not contain a strong element of direct democratic accountability. Introducing greater democracy would mean more than just structural change: introducing electoral accountability would involve patients and communities and would provide an opportunity for public debate and greater access to information. The bill would lead to a sea change—as Unison contended—in the culture of NHS boards. That would be a very good thing.
Having said all that, problems with certain aspects of the bill will have to be rectified at either stage 2 or stage 3. If I have a major disappointment, it is that the Government has included in the bill a provision that
"councillor members and elected members of a Board must"
form a majority of the board. Let me say right away that I have nothing against councillors being appointed to boards. Indeed, their appointment was a welcome innovation of the previous Labour-led Executive. Councillors make a valuable contribution. However, I remain firmly of the view that they should not count as directly elected members of the health board. They are not directly elected to a health board; they are appointed by ministers. At stage 2, I intend to lodge an amendment that will state clearly that the directly elected element of the board should be a simple majority directly elected by communities at health board elections. To do what the Government suggests would be to dilute the principle of democratic accountability. It would be a step too far.
The bill is also deficient in that it permits the cabinet secretary to remove elected board members from office. That should not happen, even in exceptional circumstances. I therefore sincerely hope that the Government will think again. It is entirely unacceptable that anyone—no matter how exalted—be allowed, even in theory, to overturn the decision of the electorate. Only the electorate can overturn such a decision—at the next electoral diet.
I stress that I support the idea of 16 and 17-year-olds being able to vote in health board elections—and I support such an extension in other types of election as well. That is a personal opinion; my political party has not yet come to a view on the issue. However, as far as the bill is concerned, I am apprehensive about the practicability of having a special young persons register, containing the details of 15-year-olds, that would not be made public. I do not know how that could possibly work. I share the committee's concern about that, and I look forward to the Scottish Government presenting specific proposals to meet those genuine concerns.
An argument often used by conservative opponents of the bill—conservative with a small "c"—concerns the politicisation of health boards. I share that fear. As suggested by Local Health Concern, there should be a prohibition on party political slates—a point mentioned in paragraph 47 of the Health and Sport Committee's report on the bill. Again, I will consider lodging a stage 2 amendment that I think will deal with concerns about the party politicisation of health boards.
Of course there is politicisation of health boards, and of course health boards indulge in politics. That is just the way of things.
Despite the reservations that I have expressed, I genuinely feel that the general principles of the bill are a welcome first step towards the positive extension of democracy and democratic accountability in our NHS. On that basis, Labour will support the bill at stage 1. I welcome the Government's endeavours in this matter.
First, I congratulate Bill Butler on all his work in this field over the years and on his wise contribution today, which I am sure that members on all sides of the chamber will take seriously.
Like most people in the chamber, I am a passionate supporter of a health service that is free at the point of need and paid for out of general taxation. However, I will tackle the question of public representation in a slightly different way from other speakers.
Ideal in theory the NHS may be, but it has one serious flaw. The people of this country were told for years that they had a first-rate health service that was the envy of the world and that it could exist, and be developed to an almost unlimited extent, without the pain of higher taxation. Normally, when we make a purchasing decision, we balance desire against cost and make a judgment accordingly. Is having four extra programmes on a dishwasher worth an extra £100? Perhaps not. But by divorcing the cost of health care from its quality or comprehensiveness, we have removed that vital link. We need to reconnect our function as taxpayers—as owners of the service—with our natural desire to ensure that it is of the highest quality, almost at any cost. We must enable the public to take part in difficult decision making, and the bill before us is one small step in that direction.
Territorial health boards are responsible for spending about £8 billion a year, which is almost as much as the amount spent by local authorities. Yet, although local authorities are subject to stringent local accountability, health boards have no such discipline. My local health board here in Lothian can be taken as an example. I know that the board is composed of dedicated, public-spirited individuals with the best interests of Lothian at heart. However, if we consider who the chairman and the non-executive members are, we would not be surprised to meet them all at the same Morningside drinks party. They are business consultants, accountants and academics to a woman or man. They have been appointed to represent the public interest, but how representative are they? Who knows their names, how can they be approached, and what do they know about the health needs of deprived areas or ethnic minorities, for example? That is why I favour direct elections to health boards.
It is perhaps not surprising that many of the protests about direct elections have come from those with vested interests in maintaining the status quo—from the "health is too complicated for ordinary people to understand" brigade. Well, I beg to differ. It is only when we have members of health boards who have submitted to the electoral process that we will begin to give local people real confidence in the way that their health service is run. If they subsequently lose that confidence, there is a remedy at the next election.
At this point, I emphasise the importance of arranging suitable training for newly elected members of health boards. At the moment, most non-executive members of a health board seem to receive their training from the executive members of that board. As a result, a master-pupil relationship develops right at the beginning, and that militates against good decision making later on.
Those who oppose the bill raise objections that require consideration. Direct elections have been tried in New Zealand and Canada, the objectors say, and have been unsuccessful. Well, although such elections may not have produced the instant transformation of health services promised by the most fervent advocates, the evidence is that they can deliver beneficial results. In the most recent elections in New Zealand in 2007, 43 per cent of the population voted in district health board elections, as compared with 41 per cent in city council elections. That does not seem to indicate that people feel such elections to be useless. In Saskatchewan, I am glad to say that researchers found little evidence of politicisation of the electoral process, or of elected members considering themselves to be hostage to majority opinion on every issue.
Does the member acknowledge that the turnout in New Zealand has fallen from 50 to 43 per cent and that the number of candidates has halved since the elections were first introduced?
I appreciate that. The number of people who voted in ordinary elections in New Zealand fell, too. That was part of the general democratic process. I believe that the number of people putting themselves forward for election to the Scottish Parliament has more than halved since 1999. It is a characteristic of democracy throughout the world. I do not think that the 43 per cent turnout in New Zealand was indicative of a lack of confidence in the procedure.
There is the criticism that elected members of boards tend to come mainly from the same narrow backgrounds as appointees, although I believe that that will change in time. No matter. At least they will have been chosen by the public to represent them and will be available in surgeries and meetings to be consulted on the issues of the day, which will be a great improvement.
We are urged by the amendment, which the Government has accepted, to consider other methods of public involvement, but what are they? It is true that there are effective patient organisations, but we are debating the role of the public as owners of the health service, not just its immediate users. There is talk of extending the role of public partnership fora, but how do people get on to those bodies? By appointment. In any case, they relate only to community health partnerships, not to health boards that are also responsible for hospital services. In addition, such fora can be as easily dissolved as formed. Independent scrutiny bodies are suggested, but whereas those are useful tools for the consideration of specific issues, they are unsuited for guiding the general direction of services in a large area, and the Scottish health council is just another appointed body. I agree with the cabinet secretary that all such activities should continue alongside direct elections, but I do not see how they are alternatives to direct elections.
In conclusion—and at the risk of giving undue succour to my Conservative colleagues—I quote Winston Churchill, who said that
"democracy is the worst form of Government except all those other forms that have been tried from time to time."
We have tried those other forms and they do not work. Let us now have the courage to embrace democracy.
This morning, rather like Dr McKee's dishwasher, I have more than one programme—I have two. That is because I have two roles to play in the debate. First, I am the convener of the Subordinate Legislation Committee, which has been referred to by other members. Secondly, I am my party's public health spokesman.
This is my big day. It is not often that the convener of the Subordinate Legislation Committee has the opportunity to talk at length about something, and I will take that opportunity with both hands. It is right and proper to put on record my and the committee's thanks to a number of people who helped us in our scrutiny of the bill at stage 1. We thank the clerks and the Scottish Parliament's legal team, and I thank the members of the committee. One of the most disconcerting things about being the convener of the Subordinate Legislation Committee was discovering that Dr Ian McKee and Jackson Carlaw read all their committee papers, so the opportunities for convener flannel are kept to zero. In praising Dr McKee, I may inadvertently have ruined his career within his party—but we will come to that later. The involvement of the cabinet secretary has been mentioned and I, too, thank her and her officials.
The committee conducted a robust examination of the bill. The letter from the cabinet secretary, dated 12 January, which has been referred to, answered some of our questions and those of the Health and Sport Committee and the Finance Committee. The Subordinate Legislation Committee is the Parliament's watchdog; its job is to ensure that the powers that are introduced in bills, which might be conferred on ministers, are reasonable and that, at all times, the proper role of Parliament is safeguarded. It is right for me, as the convener of the committee, to recognise the fact that, in the cabinet secretary's letter, there was a significant give on a number of fronts. I am sure that my fellow committee members from all parties agree with that. That is good for the Scottish Parliament, because it demonstrates that we are doing what we should be doing as a committee of the Parliament. It is also good for the Scottish Government, as it means that better legislation will be made.
I must be careful, as must all members of the Subordinate Legislation Committee, to ensure that there is a clear dividing line—like that between my two programmes—between what the committee does, which is about the legalities of a bill, the powers that may or may not be conferred on ministers and the role of Parliament, and the subject matter of the bill, which we must keep off because it properly falls within the remit of the subject committee. Therefore, the issue of the cost of the pilot schemes—whether it is one figure or another and whether it has gone above £20 million—was emphatically not for the Subordinate Legislation Committee. That was a matter for the subject committee and it has accordingly been raised in the debate already.
Speaking in my other role, as my party's public health spokesman, I note that the power that ministers will have to dismiss elected health board members appears somewhat scary. As I said in my intervention on the cabinet secretary, that would involve a minister cutting across the powers of a directly elected health board member. The cabinet secretary has given an undertaking to revisit the issue at a later stage in the bill process, and I am sure that we all await that with interest.
The issue of the identification of 16 and 17-year-old voters is also crucial. I accept Bill Butler's point that the jury is out on that one and that the devil will be in the detail.
My colleague Ross Finnie has rightly expressed the Liberal Democrats' continuing concern that the direct election of health board members could, in a bad week, set local authorities against health boards. That would be unfortunate, especially in times of limited resources when we must work together.
The issue that Mary Scanlon raised about what I might call the geographical deficit is obviously close to my heart. Members will know that I have repeatedly raised the issue to which Mary Scanlon alluded, concerning maternity services in the far north. Indeed, the very last parliamentary question that the late Donald Dewar answered was a supplementary question from me about maternity services in Caithness. That shows how far back the issue goes. It is arguable that we would never have arrived at the situation that was arrived at had the then health board had better representation on a geographic front. In my intervention on Mary Scanlon, I made the point that favouring a candidate from an area where the weight of the population lives over a candidate from an outlying area could disadvantage the outlying area. That would be in addition to the difficulties faced by people who have to travel, which Dr McKee talked about. That is a valid point for a later debate, and I make a plea that the issue of geographic representation be considered as the bill progresses.
Michael Matheson talked about the attitude, which we have all come across, that health is too important to be left to ordinary mortals, which seems to turn the debate on its head. Provided that there was geographic coverage, directly elected members could have made all the difference and could have headed off the situation that we faced in the far north long before I got to my feet and questioned Donald Dewar. That is a fair point, which it behoves us all to keep in mind.
The Liberal Democrats are extremely pleased that our amendment is being accepted by members throughout the chamber. As Cathy Jamieson said, it sends a strong signal about where we are coming from and that we must ensure that things can work before we go any further. The debate is being conducted very much in the same spirit as the interaction between the Subordinate Legislation Committee and the cabinet secretary and her team. In other words, we are all working together constructively to make better legislation. The Liberal Democrats wait with great interest to see the bill again at stages 2 and 3.
I am instinctively in favour of anything that will improve health boards' accountability to the cabinet secretary, this chamber or the public—or indeed to all three. Inevitably, we are shaped by our experiences: I, for example, witnessed at close quarters the operation of NHS Argyll and Clyde and members will not be surprised to learn that I did not find it a particularly edifying sight. My particular interest, of course, is the Vale of Leven hospital.
What I witnessed in that health board was its dismissive treatment of the community's views, its arrogant approach and its strong belief that it knew best. To top it all, there was a payroll vote at board meetings. Perhaps I should explain that a little bit more: when the chief executive of NHS Argyll and Clyde raised his hand in a vote, an array of hands belonging to the executive directors and associated employees would rise simultaneously. It did not matter what the issue was or whether the argument for a different view was overwhelming—all the hands went up. Some have said privately to me that it was probably a case of follow the boss or lose one's job. No one can convince me that that is an open and transparent way of operating—and I certainly cannot be convinced that it is in the interests of either patients or communities.
As a result of that experience, I am predisposed towards taking action to improve matters; in fact, in the previous parliamentary session, I voted for Bill Butler's member's bill. Like other members, I congratulate Mr Butler on his efforts in getting us to this point, and commend the Cabinet Secretary for Health and Wellbeing for taking the matter forward. In that context, I am happy to support the bill's general principles, while echoing some of the concerns that have already been expressed about detail.
The bill does not directly improve health boards' accountability to the public. Scottish Government officials have made it quite clear that nothing in the bill changes the current situation and that the board will still be responsible in policy terms to the cabinet secretary, whether or not its members are elected. I understand the reason for that; after all, it is important to have consistency across the NHS in Scotland. However, there is a very real possibility of creating tension between an elected member's responsibility to their electorate and their responsibility to ministers. I am thinking in particular of cases of substantial service change on which there might be a clear difference of views. Inevitably there will be frustration and, ultimately, there might even be disillusionment, which is something that none of us wants.
As Ross Finnie rightly pointed out, we need to ask fundamental questions about corporate governance; how health boards work—or, indeed, do not work; and why in some cases they are so at odds with their communities. Although having directly elected members might have a positive effect—as I believe it will—it does not solve the underlying problem of governance structures that are perhaps tired and detached.
Given that opinion on direct health board elections is very divided, we should welcome the suggestion that pilots should be carried out. Initially, the Government intended to hold two identical pilots for direct elections using STV and extending the franchise to 16 and 17-year-olds. Before I turn to the detail of that proposal, I point out that the cabinet secretary has rightly accepted the Health and Sport Committee's strong view that the Government must pilot more than one approach, and I look forward to seeing the details of those alternative pilots before we reach stage 3.
I want to raise three issues about the current pilot proposal. First, on extending the franchise to 16 and 17-year-olds, significant concern was expressed with regard to setting out details of 15-year-olds on a register with their date of majority. Such a move clearly raises child protection issues. The committee is looking for information on that point prior to stage 2 and I hope that the cabinet secretary will address it when she winds up.
Secondly, on ward boundaries, many of my constituents will be disappointed if it is decided that a ward should cover an entire health board area. In fact, I agree with Mary Scanlon on this point. How can we ensure representation from the very large and diverse geographical areas covered by NHS Greater Glasgow and Clyde or, indeed, by NHS Highland? If we do not have smaller wards, there is little chance that people in my area, who care passionately about their health service, will be elected.
The third area of concern is, as Christine Grahame pointed out, the lack of personal identifiers in a postal ballot. The Electoral Commission, local authorities and returning officers, as well as the committee, have said clearly that such identifiers must be used in a postal ballot. Given the experience of our May 2007 elections, any new elections must be rigorous and robust, and there should be confidence in the system and the people elected. The cabinet secretary has indicated that she is not minded to use personal identifiers. The committee has made it clear that, if that remains the case, she should reconsider the proposal for an all-postal ballot. If we are serious about making this work, we should follow the experts' advice and ensure that no questions can be raised about the validity of the elections.
It is essential that, before any roll-out takes place, an independent evaluation of all the piloted approaches is carried out, with further consideration of the cost estimates. As a member of both the Finance Committee and the Health and Sport Committee, I have had two opportunities to scrutinise the bill. It is fair to say that the costs set out in the initial financial memorandum were quite basic; in fact, between evidence sessions, they were revised upwards by about £3 million. It has also been pointed out to the Health and Sport Committee that the financial memorandum does not include fees for returning officers, so there is obviously more work to be carried out in that respect.
Although the cabinet secretary has made a commitment to fund the pilots, there has been no commitment to fund any roll-out centrally. The health boards themselves have suggested that that might have an impact on public engagement budgets while, in written evidence, others have raised concerns about the impact on front-line services.
That point was also raised in the committee's evidence sessions. Does Jackie Baillie accept that, although I might state a personal opinion that any roll-out should be centrally funded, I cannot bind future Governments or indeed future Parliaments in that regard? After all, these decisions might be at least one spending review and one or two parliamentary elections away.
I entirely accept that, but any indication of the cabinet secretary's intentions with regard to roll-out would be very welcome.
The bill leaves substantial matters to subordinate legislation that in many cases is subject to negative procedure. I will not repeat Jamie Stone's points in that respect, but the fact is that Parliament requires more scrutiny of these matters. I am pleased that the cabinet secretary has recognised that and I look forward to the amendments that will be lodged at stage 2.
Finally, on the bill's real-time impact, I am pleased that the cabinet secretary recognises the importance of public participation and consultation. I share her view: this bill is additional to that essential local engagement. As she will be aware, my local community is going through a consultation exercise on the Vale of Leven hospital; indeed, meetings are being held this and next week. One of my community representatives, who has campaigned about local health services for a long time now, asked an executive director of NHS Greater Glasgow and Clyde whether any of the pre-consultation discussions or written submissions had changed the content of the consultation. A deafening silence fell, and was broken by his response: "No." Although he was then rescued by another senior executive officer, the cat was unfortunately out of the bag. Changing the attitudes of and culture among health board senior executive officers with regard to the legitimacy of the community's views obviously remains a challenge, and I believe that having directly elected members on the board might make that kind of difference. I therefore support the bill's general principles.
Before I begin, I want to acknowledge Bill Butler's pioneering work on and commitment to this issue.
Having direct health board elections is fundamentally about restoring public confidence in the way in which health boards reach conclusions on issues of profound importance to the Scottish public, such as the future of hospital services—or, indeed, the future of hospitals themselves. Any changes that impact on people who have been made vulnerable as a result of illness must not only be made in their best interests, but be seen to be made in their best interests, and any rationale for such change must stand up to public scrutiny. However, as a result of what has happened for many years now in some health board consultations, the public's confidence in their being listened to has reached an all-time low. The fact that the public no longer trust health boards must be addressed urgently for the good of not only the public, but health boards.
My experience of changes to vital services that Greater Glasgow and Clyde NHS Board has undertaken is that that public body has had a predetermined agenda. No matter what the evidence has been or the number of people who have been against its proposals, it was always going to be the winner. We got what it wanted, no matter the strength of our argument.
The Vale of Leven hospital provides a prime example of a health board complying with Labour's centralisation master plan, which was going to be pushed through, no matter what the public said. The hospital had a fine record, but it was deliberately salami sliced to make it fit the bill for closure. If one bit and then another is taken away, the rest will fall. It was like undermining a building in perfect condition. It was bound to fail because its foundations were undermined. It was not until the Scottish National Party Government was elected that the centralisation agenda was challenged. In the case of the Vale of Leven hospital, independent experts contradicted the health board's plans. As a result, we still have that hospital, and its long-term future is assured with the Government's full support.
Will the member join me in asking the health board to reconsider its proposals to remove services that are currently at the Vale of Leven hospital and transfer them to Paisley?
Perhaps we could get back to the bill, Mr Paterson.
I would like to answer Jackie Baillie's question, because it is valid and fundamental to understanding why we should have elected members on health boards. She and I know about the salami slicing that I mentioned earlier. The position now is that there has been an independent evaluation of what happened, and, unfortunately—I think that we are discussing anaesthetics—that report says that it would be dangerous if anaesthetic services remained at the Vale of Leven. I do not know about other members, but I would not be brave enough to suggest that they should stay, because of what happened. It shows that, if something is removed, the bricks start falling down and there is no longer a wall.
St Margaret's of Scotland Hospice in Clydebank has made the claim, which it can justify, that when decisions were made about the removal of beds from that hospice that were funded by Greater Glasgow and Clyde NHS Board, the board did not consider how fundamental to the wellbeing of the hospice those beds were. No real consultation took place; in fact, Glasgow representatives took decisions in Glasgow on the removal of funding for those beds. At the same time, funding for the same number of beds was being committed to a new private finance initiative project in Glasgow. I am quite happy to accept that I am a cynic, but I am not the only one who can be called that. I think that everybody in Clydebank would consider themselves cynics about the health board.
Direct elections to health boards will have benefits. If people are elected, they can be removed by the public in the same way that parliamentarians can. Anybody who is not paying attention to their electorate deserves exactly what they get. People will have confidence in any hard decisions that need to be taken, because board members will be answerable to the public. As Unison said, the proposals are not a panacea for improving health engagement, but they are an important step in changing the culture of engagement within health boards.
To put things simply, although hard decisions will be taken that I am sure not all members of the public will be happy with, they will be safe in the knowledge that decisions have been taken for legitimate reasons rather than on the basis of a preconceived agenda, and that they have not been taken only by people such as health board managers, for example, who are dependent on a job and may or may not keep schtum on any given matter that is handed down from on high. I like the idea of decisions being taken on merit after debate, rather than on the basis of a highlighted recommendation on a buff-coloured bit of paper. The balance of power must shift. The public must have their say to legitimise the boards and bring back confidence into the system.
I support the concept of elected health boards. They might be a little inconvenient for those who think that they know best or they might cost a little bit of money to administer, but I have a simple question: what will the real cost be if we do not have them?
As members have said, there is no doubt that there has been growing dissatisfaction in the past few years with how health boards engage with the public on the provision of local services. We all remember during the previous session, under the previous Administration, the vociferous campaigns that were conducted to save maternity and A and E units in various parts of the country, very few of which were successful.
The enthusiasm and optimism ahead of the Kerr report, when people thought that they were, at last, to have real and meaningful input into the shaping of their NHS, soon gave way to anger and frustration when it came to the reconfiguration of local health service provision. Throughout the country, there was a sense that health boards were consulting the public on faits accomplis and pressing ahead with change in the teeth of local opposition. I am sure that I am not the only member who attended angry public meetings at which health board staff were accused of having closed minds and no real interest in local input.
It is generally recognised that there needs to be better engagement between the NHS and local communities—the cabinet secretary spelled that out, and it has been borne out in evidence to the Health and Sport Committee—but there seems to be little agreement about the best way of achieving it. The current situation is confusing. A number of bodies are responsible for various parts of public and patient involvement, such as the public partnership fora, the CHPs and the Scottish health council. There is a deal of scepticism about the effectiveness of those bodies. Only yesterday, I heard a popular practitioner decrying his local CHP. They said that it is a talking shop that is heavy with management and that general practitioners no longer engage with it. Such comments do not inspire public confidence; rather, they substantiate the general feeling that the consultation and engagement methods that NHS boards use still do not take sufficient notice of the views of patients and the public, and that the situation must improve.
In that context, I sympathise with the concept of having a proportion of directly elected members on health boards in order to give the public a place at the health board table when important matters and changes are being discussed and a direct input into the process before decisions are made. However, it is clear that there must also be significant input from professionals who are involved in running a service that is important to our wellbeing and extremely costly to run. A balance must be struck.
Two years ago, when Bill Butler proposed that health boards should have a majority of directly elected members, I voiced my concern that that could lead to short-term decision making, single-issue candidates and, occasionally, distorted priorities or delays in making difficult decisions, which could lead in some instances to care inequalities and an undermining of regional services planning. I am probably seen as part of the establishment, but I still have concerns about the bill's proposals. I am concerned about directly elected members and appointed councillors—who are likely to be political recommendations—constituting a majority on health boards, although I accept that, as a group on their own, directly elected members would be in a minority. I certainly do not go along with Bill Butler's continuing commitment to having an outright majority of directly elected members.
Other valid concerns were expressed during the Health and Sport Committee's consideration of the bill. For example, will elections to health boards result in genuine public representation or will they merely attract people who are time and financially rich or who are standing on a party ticket? As a result, will they lead to the politicisation of boards? Will the extension of the franchise to 16 and 17-year-olds lead to their representation on boards, or will time and money costs preclude that? Will the public actually become engaged with the electoral process or will there be voter apathy, as there has been in New Zealand? We know that turnout in New Zealand has decreased from 50 per cent, which it was at the outset in 2000, to 43 per cent in 2007. Will the costs outweigh the benefits? Will money be spent on elections that could be better spent on front-line services? Many questions are as yet unanswered.
I am relieved that, rather than seeking to introduce nationwide elections at this stage, the bill provides for pilot elections to be undertaken in certain health board areas. It is also right that, if the Parliament approves the bill, the Scottish Government should meet the costs of running the pilots and that those costs should not be paid out of health board budgets. However, I am concerned that if the pilots are a success and the roll-out of elections throughout Scotland is eventually approved, boards might have to divert money from front-line services to pay for them.
As there is a clear demand for the public's views to be better represented and for greater involvement in decision making, and as that is not being achieved by other methods currently, I am content with my party's willingness to support the general principles of the bill at stage 1. The proposed pilots should provide the substantive evidence that currently is not available on the workability and cost-effectiveness of health board elections.
It is important that the pilots are fully and thoroughly evaluated and that the results are presented to Parliament so that they can be scrutinised and debated ahead of any possible roll-out of elections. I welcome the cabinet secretary's assurance to the Health and Sport Committee that the lodging of a roll-out order will only follow a completely independent evaluation of the pilots and that that roll-out will depend on the super-affirmative procedure, as recommended by the committee.
The costs of direct elections are considerable, so it is right that the Government intends to amend the bill at stage 2 to ensure that the cost of the pilots and any potential roll-out costs will be fully considered as part of the independent evaluation of the pilots.
As requested by the committee—this is also the subject of Ross Finnie's amendment—it is right that other methods of increasing public engagement and involvement should be evaluated alongside the piloting of elections. I am pleased that the cabinet secretary has undertaken to present details of such methods, which will be piloted concurrently with elections.
The Health and Sport Committee is to be congratulated on its painstaking scrutiny of the bill and its recognition of the need for thorough evaluation and consideration of the results of the pilot schemes before any possible adoption of a national scheme for elections to health boards. Given the cabinet secretary's undertakings in her response to the committee following its consideration of the bill, I am content with my party's decision to support it at stage 1. However, as Mary Scanlon said, our support at stage 3 is by no means guaranteed.
I put on record my thanks to Unison for its briefing, which cut succinctly through the verbiage of objections from health boards, called a spade a spade and got to the heart of the matter when it said:
"Opposition to the Bill in the main comes from the health establishment".
Like Ian McKee and Michael Matheson, I object to the suggestion that health is too complex for mere mortals to comprehend. Implicit in many of the consultation responses that the Health and Sport Committee received is the idea that elected members would be too stupid. Indeed, I think that it was stated explicitly that elected members would be of variable quality. However, people of different abilities communicate with different people. The rather douce councillor or elected member might well be able to communicate a message more effectively to some parts of the community than would a polite professional accountant. The complexity of health issues and the size of budgets—£8 billion in Scotland and the best part of £1 billion in NHS Lothian—mean that there is all the more reason to address the democratic deficit. We are, after all, talking about vast amounts of public money.
As I drove into Parliament this morning I listened to Radio Scotland, on which doctors' leaders were reported as saying that direct elections would lead to cliques and manipulators. I argue that a lack of democracy leads to cliques and manipulators. That level of debate exemplifies the establishment desperately hanging on to the status quo and its disproportionate power and influence at the expense of public accountability and engagement.
Local authorities and elected members are not without criticism, but they make difficult and, from time to time, unpopular decisions and they prioritise resources to intervene and improve quality of life and indeed, to save lives in cases of child protection and the protection of vulnerable adults, which are complex areas. They have to make decisions about universal service provision and targeting services based on need.
There are, of course, more considered objections based on the experience of direct elections to health boards in other countries, such as low turnout, decreasing numbers of candidates and a lack of diversity among those who are elected. As Unison says, democracy is not a panacea, particularly not when it comes to improving diversity and representation of the underrepresented. We have only to look around the chamber to see the lack of women and ethnic minorities, but that is not an argument against democracy; it is a reason to find the right democratic process. It is also a good reason to have pilots.
The current system of appointments has failed to improve diversity in health boards. Indeed, the local health concern campaign expressed concerns that although the appointment system gave the impression of public involvement, people were not enabled to put forward their views through fear of deselection. I have a constituency case involving a woman from an ethnic minority who was a non-executive lay member of NHS Lothian. She is a woman of exceptional ability, non-political and non-partisan, who I believe was forced to resign in a non-transparent and underhand manner. That is an example of why the culture has to change.
Health boards have expressed some concerns about single-issue candidates. Again, they represent a misunderstanding and misrepresentation of the democratic process. The debate about the pros and cons of a single-issue candidate should be had in an election. I also suggest that it is the actions of NHS boards that have breathed life into single-issue campaigns, possibly because boards' decisions were wrong, they had not persuaded the community of their decision, they had not meaningfully consulted the community or their decisions were not transparent in the first place. We have experienced all those failings in West Lothian.
I was disappointed by NHS Lothian's evidence to the Health and Sport Committee, and I noted with interest Michael Matheson's comment that NHS Lothian said that it had consulted when, in reality, it had not. I was disappointed by the comments about an elected councillor from West Lothian who was elected on issues relating to St John's hospital. The evidence led by NHS Lothian singled him out and stated that his contribution was of limited value. NHS Lothian's evidence also said that directly elected members posed a risk of destabilising boards and contributing to a lack of unity.
Will the member give way?
No, not today, thank you.
The tenor of some of NHS Lothian's evidence would do more to damage unity of purpose and demonstrated an intolerance of difference and community concerns.
Perhaps I should not be too hard on health boards, because their views and experience are hampered by their lack of exposure to democracy—in essence, they just do not get it. I speak as a nationalist who has long been accused of being in a single-issue party. The reality is that elected members roll up their sleeves and, where there is common purpose, get on and work with their opponents for the greater good of the community. As Ian McKee said, the pilot elections to NHS boards offer an ideal opportunity for boards to embrace change and elected members.
Direct elections are desired and discussed in my constituency because they are seen as part and parcel of keeping health care local. Addressing the democratic deficit is part and parcel of celebrating value and protecting local services.
We now move to the wind-up speeches. I call Ross Finnie.
I seek clarification on that, Presiding Officer. I was invited to speak second because I moved the amendment.
I am afraid that you are first according to my script.
If I am summing up officially on the amendment, I think that I should do so after hearing from the Conservative and Labour speakers.
We usually follow the party order but, in this instance, I will call Jackson Carlaw.
I genuinely looked forward to the debate, because it seems a long time since we first touched on health board elections in this third parliamentary session. In one way or another, all parties have been prepared to explore ways to extend the democratisation of health boards but, as time has passed, the devil has proved to be in the detail. I am especially interested in understanding how all members' thinking has evolved as they have wrestled with the complexities.
I appreciate the cabinet secretary's case and her commitment to it, and I sympathise, but when members generally agree to a bill's principles we have a responsibility to play devil's advocate on the detail. One concern is that we should not overpromise. The bill will introduce public participation in determining who in a health board makes decisions, but not in taking those decisions. If the public were to take the decisions, the engagement process between health boards and the public would have to improve substantially. Perhaps the involvement of directly elected health board members will realise that, but we cannot promise that.
Bill Butler was spot on when he detailed his understanding of the public's perception of how health boards operate the consultative process and when he said that the belief is widespread that outcomes are long predetermined. Ross Finnie complemented that by emphasising that many of us lack understanding of how health boards arrive at decisions and discharge their duties.
Cathy Jamieson made a comprehensive speech that touched on many issues, but particularly on costs. We share her concern that the financial memorandum might understate the position. Mary Scanlon underscored that point.
I was not sure about Michael Matheson's point that directly elected health boards would take decisions in the interests of the public and not of health board members—I think that he said that. I might have fundamentally disagreed with health boards' decisions and with their consultative processes, but I have never felt that health board members were taking decisions in their own interests.
The member picked up what I said incorrectly. I said that health boards have, to an extent, forgotten that their purpose is to serve the communities to which they provide services. Directly elected members would provide a more focused approach to engaging effectively when listening to communities.
I am happy to accept that.
Jackie Baillie gave a balanced critique and raised questions that are of common interest to us. I noted her point about the size of wards. She was right to say that voters in the NHS Greater Glasgow and Clyde area who live in East Renfrewshire would be unlikely to be concerned about what is happening in the Vale of Leven hospital, if they have even heard of it. Similarly, people who live in the Vale of Leven might be unconcerned about what is happening to residual geriatric services in Mearnskirk hospital. Ward size is a potential factor in public participation. However, as my colleague Mary Scanlon made clear, we will support the bill at stage 1.
As a Subordinate Legislation Committee member, I join Jamie Stone in acknowledging the cabinet secretary's explicit response to the concerns of the committee, on which we serve with Ian McKee and others.
I say to Ross Finnie that discussions of the super-affirmative procedure are the stuff that keeps the Subordinate Legislation Committee going. At one point in the debate, I saw that about half the members in the chamber had been members of that committee this session. I am sure that they will testify that such discussions have all the fizz of a sparkling champagne.
Will Jackson Carlaw enlighten the Parliament and explain in detail the super-affirmative procedure?
I fear that time does not permit that, even when the opportunity to speak is open ended.
Will the member say what champagne he drinks?
In relation to the discussion that we are having, it is flat.
I will elaborate on a few matters that we need to understand more clearly if we are to support progress on pilot areas at stage 3. Our manifesto contained a commitment to support direct elections, but my confidence has been, if not shaken, certainly stirred by a deeper examination of the practicalities and potential consequences.
When the subject was first raised, I wondered about directly elected members' ability to participate meaningfully in the detailed discussion of many substantive health issues. A feature of boards has been the widespread public perception that lay members have often felt obliged to defer to clinical or professional managerial experience, which is passionately represented, because lay members lack alternative advice or experience or the confidence to go out on a limb and oppose others' wishes. The cabinet secretary imaginatively addressed the potential consequences of that situation at the extreme by establishing her independent scrutiny process, which allowed her to refer a decision by an appointed health board to independent scrutiny. As we all know, that was crucial in vindicating those who fought long and hard against proposed A and E closures.
In similar circumstances, how acceptable would such a referral be if the decisions were made by a health board the majority of whose members were directly elected? Surely that would make a referral more politically difficult and questionable. We need to be assured that all directly elected members, who might well—although not necessarily—possess less working knowledge than appointed members, will have access to independent advice and support. That might be easier said than done, but if we are not satisfied of that, we could make dealing with issues that are of enormous public concern more difficult than at present.
Members have referred to the practicalities of standing for election, which reminds me of the arguments about establishing the Parliament. Some hoped that the Parliament would not be organised on party lines and that it would be a Parliament of all the talents. We have a distinguished independent member and other independent members have been elected, but the reality is that the requirement for the apparatus to mount and sustain a campaign leads inevitably to the involvement of political parties. It is therefore difficult to argue with certainty that in larger health boards at least, the practicalities of mounting an effective campaign would not be insurmountable for individuals, so we might end up with party-politicised health boards. That would be unhelpful. Heaven forfend that politically ambitious elected health board members should showboat in a dry run for political advancement and posture for political expedience rather than act in the NHS's best interests. We need more evidence on how genuinely independent candidates are expected to manage an effective campaign and on how they are to manage the geography of a health board area as they represent the community in it—Mary Scanlon mentioned that.
How engaged the public will be is suspect on the basis of international evidence. Ian McKee quoted the figures from New Zealand, which showed a lack of engagement in local elections and health board elections, from which we cannot take comfort.
The British Medical Association made the practical point that an older person—perhaps one who suffers from cancer—could be appointed as a board member, but that such a person would be unlikely to stand for election. Direct elections could mean that some demographics would not be represented on boards, because of the age of people who felt able to participate in elections.
The proposal that the cabinet secretary should be able to dismiss elected members is curious—Bill Butler and others touched on that. I appreciate that she can dismiss appointed members—that is not peculiar—and that since a minority of members will still be appointed, all must be treated equally. However, the principle is somewhat curious.
On balance, we support the principle of having pilots. However, if we are to commit funds to them, we will need to be convinced at stage 3 that they are realistically expected to succeed.
Presiding Officer, I apologise for forgetting that, in our standing orders, amendments are irrelevant to winding up debates. My personal opinion is that that is curious, but that does not reflect on your good self.
I say to Jackson Carlaw that, as a substitute member of the Subordinate Legislation Committee, I am all too familiar with the fizz and excitement that pervade that committee as it proceeds not line by line as subject committees do, but comma by full stop, definite article, less-definite article, subject, noun, object and—occasionally—verb.
Prepositions.
Prepositions, too—occasionally. I am well aware of the situation.
More important, my claim to fame on the matter is that I am aware that the super-affirmative procedure is not new. It has not been created for this purpose. To my knowledge, the procedure has been applied on at least two previous occasions.
Will the member take an intervention?
Not on a comma or other grammatical matter. When I reach a more substantive point, I will be happy to take an intervention.
The debate has been interesting and constructive. Indeed, it has exposed the difficulties that surround the management of heath boards and the range of views that contribute to the process.
Bill Butler made an excellent speech, in which he articulated the position that he has long held on the need for directly elected health boards. However, he also wishes to introduce elements that are perfectly legitimate but which raise questions on what we mean when we talk about the structure of health boards. Bill Butler's concerns may prompt him to lodge an amendment, the aim of which would be for directly elected members only to count in the majority. His proposal raises interesting questions, including the question whether the votes of councillors—given that they are appointed and not elected members—should be discounted.
Another issue is the position of the non-executive chairman. If the arrangement is for the non-executive chairman and all other non-executive members to hold to account the executive, it would be curious indeed for us then to say, "Well, that is what you are supposed to do, but actually you do not have the same rights as them." If people are asked to hold to account an executive, the non-executive chairman and all those who are not directly elected—those who are, to use the more pejorative phrase that Jackie Baillie introduced into the debate, the payroll vote—should be separate. That should be made clear to them, irrespective of whether direct elections are introduced.
In terms of the payroll vote, perhaps the solution is to return to the situation of the late 1970s, when the people who held those positions sat on boards simply to give advice.
Curiously, I was about to address the matter. I understand that Unison holds that position, although I should make it clear that it said in evidence that, although it would go along with the proposal as far as it goes, it wishes to see health boards run on identical lines to local authorities.
With respect to Bill Butler, although debate on the issue that he raised is legitimate, it is not the matter that the cabinet secretary has brought before the chamber. She is not suggesting any change to the process for appointing those who are appointed to executive roles because of their clinical expertise. If one makes the argument that clinical expertise should be retained on an executive, one must also make it clear who the non-executives will be, who will act together and who will hold the executive to account. My concern is the great lack of clarity that there appears to be across Scotland on the matter.
Michael Matheson made a typically robust speech. However, when he and other members spoke about problems on health boards, I was struck by the fact that, although they spoke about health services, almost to a person they focused their remarks on hospitals. Given that 80 per cent of care is provided in our communities and only 20 per cent is provided in hospitals, there is a degree of dishonesty in making hospitals the great focus of attention. I accept that the situation might not change until we have more honest public debate on health service provision and where services are to be provided.
Ian McKee gave another typically robust speech, in which he spoke of the inadequate procedures in the appointment of board members. If people do not understand their role or if the wrong people are being selected, from a narrow choice, it begs serious questions on our procedures for appointment if an element of democracy is not involved. The question is equally valid across all forms of public life.
That issue leads me to address another area of difficulty: how to appoint those who hold executive responsibility. If we end up with a master-pupil relationship, something is fundamentally wrong with the appointment process. If appointees believe that they form part of an echo chamber for the executive, they clearly lack understanding of their role in the organisation. Those points will not disappear simply because we bolt on another structure for the appointment of non-executive directors. That is the fundamental point that I want to raise in this stage 1 debate.
The Liberal Democrats remain sceptical on the subject of direct elections to health boards. Democracy does not happen simply by having elections; it operates and functions properly in a range of structures, all of which have to be put in place and to operate in what I would describe as a liberal democracy. Elections do not of themselves produce a responsive democratic result. That remains my position.
I am pleased that there is unanimous support for the Liberal Democrat amendment, which places on the record the expressed views of the Health and Sport Committee. The wording of our amendment was lifted directly from paragraph 123 of the committee report. Our intention in so doing was to reflect accurately the committee's findings. As Mary Scanlon said, we must be honest and open in the debate. On the basis of the evidence that was given to the committee, the case for direct elections was not wholly made.
I accept that some board members and boards display a lack of connection with the public view. That said, we should not denigrate all those who serve as non-executive directors on health boards. They are not some alien species who have an agenda for doing great harm to communities. Appointees may not wholly understand their role, the basis on which they were appointed may not be understood by the public, and the people with the right qualifications to fulfil the job may not have come forward. Notwithstanding all that, those who are appointed are not necessarily misguided.
The Liberal Democrats support the general principles of the bill. As I said, I am glad that there is widespread support for our amendment.
Clearly, there is almost unanimity across the chamber for the principles of the bill. In no small measure, that is due to the work of the Health and Sport Committee and to those who gave evidence and responded to the consultation. I pay tribute to the responses that the cabinet secretary made in working with the committee. She also worked with the grain of the committee report in agreeing to make changes to the bill at later stages.
Cathy Jamieson outlined some of the history. There is no doubt that there is still a considerable measure of public dissatisfaction with the workings of health boards. That is notwithstanding the fact that since the Stobhill inquiry report—on which I had the pleasure of acting as reporter to the Health and Community Care Committee and which led to significant change in the consultation process at the beginning of the Parliament—we have seen the decluttering under which the number of boards fell from 42 to 14; the implementation of patient-focused public involvement in 2004; the creation of the Scottish health council in 2005; and the latest innovation of the independent scrutiny panel. From the evidence that the committee received and the general public discussion to which many members have referred, there is no doubt on the matter.
I think that we all can agree on the need to strengthen the public consultation process. Albeit that many members have made the point, it is important that we all say on the record that direct elections to health boards will not of themselves entirely solve the problem. The purpose of the bill—I hope that it achieves it—is to improve the accountability of boards. Among many members, Jackie Baillie, Michael Matheson and Gil Paterson referred to public dissatisfaction about the perception, at least, of the lack of accountability.
A number of members including Ian McKee and Angela Constance raised the issue of the diversity of boards. Based on Inclusion Scotland's evidence, it is true to say that the boards do not have wide representation. That is the case for those who apply for board membership and for appointees. Indeed, women make up 35 per cent of board membership and yet form 52 per cent of the population. The age range of the majority of those appointed is between 51 and 60. There is also an underrepresentation of the disabled, although there is reasonable representation from the black and minority ethnic community, in that representation is almost equivalent to the BME population of Scotland.
Bill Butler and other members, including Michael Matheson, referred to the need for a change of culture. That is perhaps the bill's most important potential achievement—we will see from the pilots. The culture needs to be changed. The decision by diktat, which was manifest in most boards in the 1990s, has changed to a culture in which attempts at consultation are made, but the diversity of consultation and the variations in practice have not yet been ironed out by the Scottish health council—although it is only just over three years old. It has some way to go to ensure that best practice is followed in consultation. Whether that is done using an open forum, citizens' juries, or independent facilitators, the measures that are taken must provide confidence. If boards give answers of the sort that Jackie Baillie mentioned, and it is revealed that no changes were made to the consultation process despite various pre-consultation discussions, that betrays a continuing attitude problem. The cabinet secretary and other members have indicated clearly that boards will still need to take some very hard decisions that will be against, or will appear to be against, certain communities.
Today's debate has sparked some interesting discussions, some of which do not come under the general principles of the bill that is before us, although they will nevertheless be important for the Parliament to consider. The structure of the board as a whole is important, not just the questions of directly elected members and of the appointment of lay members and how the lay membership might be made more diverse. There is a question around the role of executive members and whether they are in effect a composite group, the bulk of which, as a result of their health expertise and knowledge, are able to exert a disproportionate effect and act as a payroll vote, as someone described it. As a collective, their contributions might have an overbearing effect on boards. Perhaps we need to address that in future.
The issue of whether board membership should be 50 per cent plus one directly elected, or 50 per cent plus one local councillors and directly elected members will be determined at stage 2. Bill Butler has indicated his intention to move an amendment to apply the minimum to directly elected members. I very much welcome the fact that local councillors will have a legislated-for position on health boards, which will be helpful.
One pilot that the cabinet secretary might like to consider would be to have 50 per cent plus one councillors on one board. That would certainly be a lot less expensive, and it would incorporate the local communities' views—councillors can be dismissed if they oppose the wishes of their communities.
Most members have welcomed the intention to consider other pilots. Another pilot might be to give money to a board to strengthen the consultation processes in a way that is proportionate to what the elections would have cost. We could see what difference that makes. Hopefully, we are genuinely proceeding with what we have all agreed is necessary.
Many members stressed the need for an independent review. That will be important for establishing the benefit of the directly elected boards under the pilots.
Many of the problems to which members have referred involve the postal voting system. Christine Grahame, Cathy Jamieson and others indicated that, if the elections are to be valid, postal vote verification will probably be necessary. We have had trouble with elections before, and we do not want something to happen with the postal vote—perhaps because of a strong community issue—that would throw discredit on to direct health board elections. We recognise that postal voting would increase the costs.
Members raised the issue of 16-year-olds and 17-year-olds voting; the problem is not so much their voting, but whether the register, which would include 15-year-olds, should be open. That is a significant problem.
The costs of the election pilots have risen from £2.85 million to £3.63 million. The costs of the elections themselves have already risen from £13.5 million through £16.65 million to £20.52 million, if we include—according to the letter from the cabinet secretary—postal vote verification. I am sure that she will correct me during her summing-up speech if that is wrong. The Royal College of Nursing was concerned about the diversion of funding from front-line services.
Mary Scanlon and Jackie Baillie referred to the problem of the diversity in size of boards, and asked whether different constituencies within the board areas could be represented. That is indeed a significant problem, which will need to be examined closely. The need to ensure diversity and equality in the boards in totality once elected members join appointed members will create considerable administrative problems if we are to ensure that all groups are represented.
The pilots will allow us to test the important point on which the Parliament now appears to be entirely agreed: given that the current boards, notwithstanding the best efforts of lay members, are still not adequately accountable—or are not perceived to be adequately accountable—changes are necessary. The pilots, which our party will support—including the Liberal Democrat amendment—will test that adequately. They will allow us to ensure that Scotland's health boards are recognised by their communities as accountable.
I thank everyone who has contributed to the debate, which has been good and constructive. It has brought to the fore some important practical and philosophical issues.
First, I will respond to some of the points that were made in the opening speeches, beginning with Ross Finnie. Before this morning's debate started, Ross Finnie promised me a Shakespearian performance. I will leave it to others to make up their minds; for my part, I think that he delivered admirably. I count Ross Finnie among the bigger sceptics when it comes to direct elections to health boards. I have always found that passing strange, given that his colleagues south of the border are enthusiastic supporters of directly electing people to health authorities. I think that I detected a possible softening of Ross Finnie's position, however. If I was a Labour minister, I might refer to that as the green shoots of conversion—but I will leave that there.
Ross Finnie suggested that the bill did not start from the right place. I disagree on that. The principle of democracy is always exactly the right place to start. However, I agree with Ross Finnie's view that the corporate governance of boards and the roles of non-executive members need to be better defined. There is some merit in that. Ian McKee was right to say that we must ensure that non-executives have the right training for the roles that they are asked to undertake. However, those arguments are neither here nor there in the consideration of whether those non-executive members should be appointed by ministers or directly elected by the public.
A restrained Christine Grahame is not a sight that I am used to; I am sure that it is not a sight that I will get the opportunity to become used to. Christine Grahame mentioned Bill Butler's contribution, and I add my thanks to him. Bill Butler did much to progress the case for direct elections, and I can tell that he is delighted to have a Government in place that backs his view on the issue.
Christine Grahame reiterated many of the Health and Sport Committee's recommendations, and she acknowledged that I have responded positively to many of them. Jamie Stone also made that acknowledgement when he spoke on behalf of the Subordinate Legislation Committee.
On Cathy Jamieson's speech, I am pleased to have Labour's support for pilot elections—at least at stage 1. Cathy Jamieson was right to narrate some of the improvements in public engagement that have taken place in recent years. NHS boards have come in for a fair bit of criticism today. I acknowledge and pay tribute to the work that boards have done in recent years to improve the quality of public engagement. The bill is not a substitute for that; it builds on and develops the work that has gone before.
Cathy Jamieson and other members raised the issue of 16-year-olds and 17-year-olds and private registers. I can inform members that, following discussions with electoral registration officers, we have, I think, identified a way forward, which will allow them to record details of 16-year-olds and 17-year-olds and attainers in their own way, using solutions that are right for them locally. I have no doubt that we will discuss that issue further at the later stages of the bill. It is important to remember that the vast majority of relevant data for 16-year-olds and 17-year-olds is already on local government registers in the form of attainer materials.
Cathy Jamieson, Jackie Baillie, Nanette Milne and possibly other members mentioned the costs of roll-out. It is important to stress that the evaluation that we propose will include a full assessment of the cost. It will ultimately be for the Parliament to consider the costs in the context of the decision that it makes about the roll-out of elections. As I stated at the committee, my opinion is that, should roll-out happen, the costs should be borne centrally. However, as I said in my intervention on Jackie Baillie, I cannot bind future Governments or Parliaments.
Mary Scanlon pointed out that the bill is not wholly welcomed. She is, of course, absolutely right. That should not necessarily surprise us, because no radical change ever attracts unanimous support. As Michael Matheson said, it is not surprising that the people who would be most affected by the change—should it happen—are, at this stage, the least enthusiastic. However, health boards have worked hard to improve engagement and I have no doubt that they will also work hard to embrace elections if they happen.
Mary Scanlon welcomed many of the suggested amendments, although she raised a number of other issues, such as distance. In geographic areas such as the Highlands, distance is an issue whether members are appointed or elected. That is one of the reasons that she is enthusiastic—as I am—to advance and extend the use of technology such as videoconferencing in the NHS.
Mary Scanlon asked how easy it would be for a minister to overturn decisions that had been taken by directly elected boards. Having overturned health board decisions, I can tell her that it is never easy, regardless of how the board is put together. I hope that having directly elected members on boards would minimise the need for decisions to be overturned, although I readily acknowledge that it would not remove it altogether. Decisions that require ministerial approval will always have to be considered carefully case by case, and no minister who decides to go against a local board will find it easy.
Jackson Carlaw, Mary Scanlon and Richard Simpson raised issues with the size of electoral wards. There are judgments to be made on that, and the judgment at which the Government has arrived is that single-ward areas and STV diminish the chances of single-issue candidates dominating elections. On the other side of the debate are the issues that Mary Scanlon and Jackson Carlaw raised. People in one part of a health board area will not share the same priorities as those in other parts. Ultimately, it is for the Parliament to decide where the balance should lie.
Our proposals in the bill undoubtedly represent a significant and radical change. Involvement and participation in the NHS must extend right into the board room. Ross Finnie is absolutely right that the discussion about better involvement too often centres on involvement beneath the board level. However, direct elections will ensure that the public voice is heard at the board table.
I agree with all members who, like Angela Constance, take issue with the idea that health is too complicated a matter for mere mortals to be involved in. I make no apology for the fact that the bill is a radical move. As Michael Matheson said, the NHS spends record sums of public money: almost £10 billion every year, which is nearly a third of the Parliament's budget. Gil Paterson is right that those spending decisions have a direct impact on people's lives. Ian McKee was also right to point to the important relationship between decisions and their cost impact.
Given Bill Butler's contribution to the overall debate, I conclude by reflecting on something that he said and with which I agreed thoroughly. The bill does not mean that all—or even most or many—decisions that health boards take are wrong. I agree with Ross Finnie that the people who labour away in our health boards are doing a good job and tend to be doing it for the right reasons. Nor does the bill mean that health boards will no longer take decisions that are difficult, are unpopular or will be campaigned and protested against. However, it will mean that, in future, all those decisions will be influenced by the people who feel their impact. That is right. It is an important step forward and it builds on the work that has been done and what has been achieved to date. It is also why I am pleased that it appears that the general principles of the bill will be approved at stage 1. I look forward to the further discussions that will come at stages 2 and 3.