Health Boards and NHS Trusts (Public Consultation)
The next item of business is a debate on motion S1M-656, in the name of Mrs Margaret Smith, on behalf of the Health and Community Care Committee, on health boards, NHS trusts and public consultation. I invite members who want to take part in the debate to press their request-to-speak buttons now so that we can see how many need to be included.
On behalf of the members of the Parliament's Health and Community Care Committee, I welcome the opportunity—[Interruption.] I welcome the opportunity to watch Iain Gray wreck the furniture and to open the first debate initiated by a subject committee. Members are a little sparse on the ground this morning. There must be something going on somewhere else. We all know about that.
I take this opportunity to pay tribute to our committee clerks and to our researcher for their hard work and input into the committee's work to date, which I will outline. I pay tribute also to the tremendous contribution of MSPs of all parties to the committee. In the months and years to come, the committee will play a significant role in the improvement of health services in Scotland.
It is significant and a sign of the changing political climate in the country and in the health service that we have decided to initiate a debate on accountability and consultation. The debate should and must send a clear signal that a new light of scrutiny must fall across the work of the health service. The debate must place the rights of patients at its heart.
During recent months, the committee has become increasingly concerned that, despite reassuring words in Government document after Government document over many years, people still feel that their voices are not being heard by health boards, health trusts, professionals and politicians. People believe that we have a national health service in which clinical voices will always be heard above lay voices. They believe it is a service in which, historically, the culture is one of secrecy rather than of openness; in which managers would rather hide information from the public and the media than engage with them to improve the quality of care; in short, that we have a secret service.
We all know the benefits of consultation. Indeed, in the debate earlier this morning, we heard that even this Parliament does not always get things right. I am sure that my committee colleagues will agree that we still have a lot to learn about how to consult bodies in the health service on the committee's work. Nevertheless, the Parliament seeks to engage in effective consultation with those bodies.
One of the key aims of the consultative steering group was to make the Parliament open and accountable and, through it, to make others more accountable to the public. The committee will play its part in that wider vision in several ways: through taking written and oral evidence; through meeting and listening to individuals, groups and statutory bodies; through visits to health and community care services throughout Scotland, beginning with our review of community care; and through working in innovative ways with users, carers and patients.
Our role includes scrutiny of the Executive's legislation and health budget and investigation of major areas of local and national concern. We have already called several boards, trusts and others to give evidence to the committee and to be scrutinised by us. It is likely that by the end of this first parliamentary session, each and every health board in Scotland will have been called to give evidence to us publicly about the state of the health service across the country.
The Public Petitions Committee plays a crucial role in making us more accessible. The committee, which acts as a public gatekeeper to our parliamentary procedures and processes, has passed two petitions to the Health and Community Care Committee that I want to mention in relation to the need for greater accountability and better consultation in the health service.
The first petition, which had 25,000 signatures, was presented by the Stracathro staff action committee. It highlighted concerns about the possible closure of the Stracathro district general hospital in Brechin. The second petition was presented earlier this year by the Glasgow North Action Group and concerns the proposed siting of a medium secure unit in the grounds of Stobhill general hospital in Glasgow. The motion refers to the first of those petitions, but the concerns of the committee outlined in the motion relate to both, and to a wider range of anecdotal comment that we have received.
It is perhaps useful at this stage to mention to colleagues that committee members have taken the view—and will probably continue to do so—that although petitions may refer to local services and situations, the role of the Health and Community Care Committee should be to take a national view and to learn strategic lessons from local examples. It should not be for us to deliver or overturn local decisions.
The committee decided, as part of our Stracathro report, to focus on communication and consultation with patients, staff and the wider communities of Angus and the Mearns, as well as on other aspects of the management of hospital resources. It became clear from the evidence that we took that there had been faults in the consultation process, including a failure to hold public meetings in key areas, and a poor standard of communication between Tayside University Hospitals NHS Trust, its predecessor trust, Tayside Health Board, patients and concerned groups. Critically, there was a failure to work in partnership with staff. We found that staff had been inadequately consulted and had found out about closures and changes through the media. Their morale and recruitment problems had worsened because of continuing uncertainty.
Compare that with the warm words of the new human resource strategy, "Towards a new way of working":
"we need to ensure that . . . as change impacts on employment and jobs, an employee relations framework is created which gives staff the opportunity of real consultation, involvement and the ability to influence decision making".
The Health and Community Care Committee agrees with that whole-heartedly, but has expressed its concern at the difference between that aspiration and the way in which hard-working, dedicated professional staff had been treated at Stracathro. We recommended that the board's and trust's non-compliance with the terms and spirit of that strategy should be investigated by the Executive in the accountability review of boards and trusts. We recommended that staff at all levels should be consulted timeously at all stages of the acute services review in Tayside.
The thousands of men and women who staff our health service are its backbone and they should be treated with respect. It is obvious that that means decent pay and conditions, training, educational opportunities, family-friendly and safe working conditions and decent environments in which to work; it also means that they must be encouraged to make an early input into any discussions about service changes and new initiatives.
We can improve the quality of our health services by working in partnership with staff at all levels, listening to their concerns and channelling their expertise. Many of our concerns that arise from our examination of the situation in Tayside have been heightened by the latest petition concerning Stobhill. We have been led to make a series of key recommendations.
I am sure that my colleagues, particularly the Health and Community Care Committee's reporter, Richard Simpson, will wish to comment in greater detail on the complex situation there. I wish to highlight a few of our recommendations and then move on to the wider picture.
The fact that the health service is lacking clear guidance on proper and effective consultation has been highlighted. Despite our finding the consultative process of Greater Glasgow Health Board to be flawed, we are bound to note that it has gone further than it is required to do to fulfil its statutory obligations. The sad truth is that there are no guidelines advising health boards that they have to inform, engage with and consult staff and the general public about new proposals, such as the new medium secure unit, or the walk-in, walk-out ambulatory care and diagnostic unit, which is planned for the same site.
Whereas there are no guidelines for consultation on new service provision, the guidelines for consultation on the change of use or closure of facilities are 25 years old—older than Duncan Hamilton, a member of the Health and Community Care Committee. Much of what is in the management executive letter from 1975 is good. It tells boards to consult all bodies with a valid interest and gives some examples—health councils, staff associations, local authorities and MPs—but it falls silent on the wider needs of the public at large and leaves it to boards to determine the necessary range of consultation. That is just not good enough these days. There is no excuse for a modern-day health service to be guided by such archaic rules. That is why we have asked the Executive to deal with the concerns as a matter of urgency, to draw up guidelines and to instruct health boards to draw up interim consultation programmes immediately.
Given the Executive's commitment in "Designed to care" to create a partnership between patients and the professionals who care for them by giving both a bigger say in the design and management of the national health service, I hope that the Executive will embrace our suggestions.
Over the years, successive Governments have published a range of booklets and other publications that outline the need for consultation. That on the closure and change of use of health service premises, the code of practice on openness in the NHS, "Designed to care", "Towards a new way of working", "Consulting Consumers" and the carers strategy are just a few of them.
However, rather than being at the heart of the consultation process, the public have often been treated as an afterthought or an inconvenience. Too often, the practice on the ground is different from the aspiration in the policy document. Some health professionals desperately want to engage with the public, their patients, but do not know how to. We should not underestimate the fear factor. Consultation and accountability are not easy. We, of all people, should know that.
There should be a clear strategy and clear guidelines that cover the minimum levels of consultation and give examples of best practice. Clinicians, for so long treated by so many as some form of deity, will have to engage with the public, but we cannot expect them to do so effectively without proper training and guidance. Further, we cannot expect health service bodies to do so without the relevant back-up and financial support from the centre to make representative participation a reality.
If we are serious about involving patients more in decisions about health care, either at the level of their own treatment or at the level of local service provision, they must have access to good information. If we are serious about planning and delivering services from the perspective of patients, we must involve them and give them the tools to make effective contributions. Without proper information, patients will either uncritically defer to the views of professionals or make ill-thought-out, nimbyesque decisions that fail to consider the full picture of service provision.
Provided with accessible and appropriate information, patients are a valuable asset. The Scottish Consumer Council is right to point out that service providers have much to learn from consumers, who are an expert resource. Knowledge of people's experience of illness, disability and using the health service is invaluable. We must all be honest enough to acknowledge that, sometimes, even the best consultation process will result in hard choices having to be made and people being disappointed. There will be times when we will have a responsibility to step back and see the wider picture. Everyone has that responsibility—health service managers, professionals, members of the media, politicians and patients.
If we want to have a better-informed patient base, we must find ways of engaging in continuing consultation and involvement, and not just have one-off meetings in public halls. The service's consultation techniques must evolve to make use of new technologies. There must be a move away from traditional public meetings towards the use of citizens juries, quantitative surveys, carers and users groups, road shows, stakeholder conferences and so on.
At all times, the changing health service must try to retain public confidence. Of course, that confidence will be built by greater funding and better services, but it will also be built by more openness, through measures such as the Freedom of Information Bill, and greater accountability. At the moment, the accountability of health boards, trusts and health councils can be called into question because of the democratic deficit. In our Stobhill recommendations, we ask the Executive to consider options to address that deficit, either through the direct election of health commissioners to the bodies or through the involvement on those bodies of local elected representatives such as councillors or MSPs.
The Executive has a crucial part to play in modernising the system of public appointments to NHS bodies. I am happy to say that that is being taken seriously. It is critical that public appointments are made on merit and are not just jobs for the boys—I use that term advisedly—or political appointments. It is essential that we get the right people in the right place at the right time and that we widen the range of people serving on those powerful bodies. I believe that there is a role for parliamentary scrutiny of those appointments and favour some form of pre-appointment scrutiny, possibly by parliamentary committees.
Scotland's health councils are the only publicly led statutory organisation representing patients and have a right to be consulted on service changes. That puts them in a powerful position. While we acknowledge that they do a great deal of good work, we retain concerns about their funding and the fact that council members are partly appointed by the health board, which might call into question their independence.
Health councils and elected representatives could play a stronger role in terms of scrutiny and accountability by, for example, attending the annual accountability review to comment on boards' performances in relation to, say, public involvement. Currently, the management executive holds health boards accountable for their performance at an annual accountability review meeting that covers many other subjects. Health councils are now asked to comment on health board performance, but are given only a short time in which to do so and are not invited to attend the private review meeting.
Public involvement must be regarded as an integral part of the health service in the acute and primary care sectors. In primary and community care, well-thought-through patient involvement may have the most significant impact in the creation and development of local health board care co-operatives and other new service developments. There must be a place for patient and user input to ensure that the services that are delivered are what patients need.
Many of the public involvement issues of recent years have arisen through the decommissioning of long-stay facilities and the move towards care in the community, along with the impact of acute services reviews. Although changes to acute services are always more likely to generate petitions and public concern, the voluntary sector and others are right to be concerned about funding issues, equity issues—such as postcode prescribing—and issues that arise from care in the community.
The onus is now on us to lead an honest debate on what the NHS can and cannot afford. The onus is on our citizens to decide whether they want to pay for health services through taxation, through increased taxation or by other means. Only last week, Dr John Garner of the British Medical Association said that it is time for the Government to admit to rationing in the NHS and for the general public to engage in a debate on what the NHS should offer. There is a role for all of us in that debate.
In placing the rights of the patient at centre stage in this first committee debate, I would like to end my speech on the subject on which I began, by stating the Health and Community Care Committee's commitment to open and accountable government at all levels of health care. We will monitor the Executive's response to our work on this matter and, through our continuing work, seek to consult and engage with patients and professionals throughout Scotland.
The committee is part of a new multidisciplinary health force that will improve health care in Scotland. We are determined to play our part to the best of our abilities. The latest priorities and planning guidance for the NHS says that the NHS should give renewed impetus to its efforts to involve patients in the planning and delivery of care and should respond positively to their views and preferences.
I commend to Parliament the Health and Community Care Committee's report into Stracathro and our on-going work as examples of our commitment to placing patient care and involvement at the heart of our health service and to tearing down any remaining vestiges of the veil from the secret service that is—or was—our health service.
I move,
That the Parliament notes the concerns of the Health and Community Care Committee, in relation to the accountability of health boards and NHS Trusts and notes the need for a new approach to public consultation as illustrated in the recent and ongoing work of the Committee, and in this connection the Parliament notes the 9th Report, 1999 by the Committee, Report on Stracathro Petition PE13 (SP Paper 48).
I welcome this opportunity to address the Parliament and I thank the Health and Community Care Committee for raising these important issues. Several important points have been raised during the committee's deliberations over the two petitions to which Margaret Smith referred. We are giving careful consideration to the report's individual recommendations, which we welcome as a valuable contribution to the work that is already under way to make the NHS more responsive to the needs of individual patients, the preferences of the public and the views of its staff.
The two reports have in common an expression of people's real concerns about proposed changes to their local NHS. I welcome the fact that the committee acknowledges the importance of local decision making. This Executive is committed to change in the NHS, because without change we cannot deliver on our commitment to provide the people of Scotland with a world-class national health service—an NHS that cares as well as cures. If we are to embrace change, we must engage, in a meaningful way, with the people in communities who will be affected. We must build a partnership that is founded on trust and a willingness to share information, and we must consult meaningfully. That is our policy.
The process has already begun. The white paper "Designed to care" sets out a clear and challenging agenda to ensure that every aspect of NHS care is designed from the perspective of patients. Each board and trust has been required to designate an executive director with responsibility for patient and public involvement. We believe that we have started to experience the benefits of that. For example, the board meetings of all health boards and trusts are now open to the public; the good practice guidance on public involvement that is set out in the Scottish Consumer Council's report "Designed to Involve" is being implemented; local health councils and other planning partners are now involved in the strategic development of health improvement programmes; and patient groups are being involved in the on-going work of trusts—for instance, in overseeing the elimination of mixed-sex accommodation.
The minister's comments are welcome, but will he accept that there are still grounds for concern? For example, I heard a representative of the health council in Glasgow saying recently on the radio that it had no knowledge of the plans for health in Glasgow. Will he accept that there are areas where consultation and communication are just not happening?
Indeed, and the next thing I wanted to say is that there are no grounds for complacency. We are at the beginning of a process of continuous improvement—I may be able to come back to the situation to which Mr Henry refers.
There have been calls, which Margaret Smith repeated today, for the Executive to issue guidelines to health boards on informing and consulting staff and the general public and on the accountability of health and trust board members. We are doing that. We agree that the 1973 guidance is outdated. We have begun discussions on revising and updating it. We would be happy, too, to enter discussions on revising and updating Duncan Hamilton, since he is of the same vintage. Perhaps that is what we try to do day in, day out.
Since coming to office, we have made it clear that health boards and trusts must operate, and be seen to operate, with probity and propriety and to be open and accountable to the communities they serve. If any of them still believe they can operate as a secret service they will not be able to hold that belief for much longer. They must involve patients, their carers and families, staff, the local community and elected local representatives in decisions about services being provided in their areas.
Does the Executive have any proposals to substantiate that assertion about health boards not being able to carry on as a secret service—proposals that would give a health check to health boards on meeting the standards for public consultation and dialogue that the Executive requires?
We are reviewing the system of NHS governance and looking at performance indicators and related measures of accountability. Public engagement will be judged.
Codes of conduct and accountability have been in place since 1994 and stress the importance of openness and dialogue with communities. Health board and trust members have to subscribe to the codes when they are appointed. The code of accountability makes it clear that boards and trusts are accountable, through the chief executive of the NHS and the NHS management executive, to Scottish ministers. The chief executive, as accounting officer, is also accountable to Parliament.
Board members also have a clear line of accountability; they are appointed by the Minister for Health and Community Care on behalf of the Scottish ministers. As ministers, we are accountable to Parliament. Since 1995, there has been a code of practice on openness; boards and trusts must abide by the code, which was extended in 1998 to ensure that all trust board meetings are held in public.
We do not regard the codes as sufficient; they need to be renewed. We are working towards establishing the appropriate balance of advice, guidance, training and support—mentioned by Margaret Smith—and, where appropriate, statutory provision, to create an accountable, inclusive NHS fit for the Scottish people. That work will be informed by other changes, such as the introduction of the Ethical Standards in Public Life (Scotland) Bill and the freedom of information legislation under consideration by Parliament.
If members cast their minds back to the debate of 16 December, they will remember that we are committed to widening the range of people who are appointed to the boards of health bodies so that boards are more representative of Scottish life. In that debate, Susan Deacon undertook to write to every member to ask for their help and I am happy to renew that call today. We are actively seeking people from a range of backgrounds to broaden the representation on boards. Susan Deacon has written to a wide range of bodies in Scotland to try to do that.
Most boards already have local councillors as members and we want that practice to continue. I do not say that that is enough. Indeed, Susan Deacon and I have made it clear to NHS chairmen and senior managers that they must forge open relationships with staff, patients and their families, local communities and elected representatives. They must ensure that there is constructive communication about the development of service provision.
Margaret Smith spoke about relationships with staff, particularly in the context of one of the committee's reports. At a national level we have established the Scottish partnership forum, which brings together—around, rather than across, the table—NHS staff representatives, trade unions, management and Government. That way of working is being rolled out across the NHS and local partnership forums are being formed. Structures are being introduced to bring about the cultural shift to which Margaret Smith referred.
I think the committee recognises that health boards and trusts face a difficult task in redesigning local health services to provide modern and responsive care that meets real local need. Health boards and trusts also face the difficult task of engaging and communicating effectively. There will be some hard decisions to make, some of which will be met with informed and reasoned opposition, as has been the case with local fears about the future of Stracathro. I stress once again that no decisions have been made yet about the future of services at Stracathro or at any other facility in Tayside.
The minister says that no decisions have yet been made about the future of Stracathro. How does he explain the cuts and closures that have taken place? Do they not affect the future of Stracathro?
I repeat the point that the delivery of services and the balance between access and appropriate high-quality services are the substance of the acute services review. Within that framework, decisions have not been taken.
The committee's work underlines the fact that decisions may encounter understandable—although perhaps unnecessary—fears. That is particularly true if proposed changes involve mental health facilities and, in particular, facilities for mentally disordered offenders.
There is unanimous agreement on the need for a local forensic unit to serve Glasgow's population. The siting of the unit was always going to be a controversial issue that would cause considerable public and media debate. The guidance on health and social work care for mentally disordered offenders that was published in January 1999 put into effect modern thinking on care for the mentally ill. Few people these days argue that it is in the best interests of patients to keep them locked away in old Victorian institutions, miles from their families and homes.
Where possible, care should be provided in the community in an environment that maximises the possibility of rehabilitation and return to an independent life. Of course, that care has to be provided under conditions of appropriate security, with due regard to public safety. We cannot expect the public to accept that if we do not engage with them. The difficulty of getting that right was highlighted in the public debate on the proposed unit at Stobhill hospital and we must learn from that experience.
Richard Simpson's very detailed report has raised important issues for both Greater Glasgow Health Board and the Scottish Executive. We are considering the report and will respond shortly. I am confident that Greater Glasgow Health Board knows that it must learn from the experience of Stobhill when it carries out public consultation exercises in future.
Steps are already being taken in the Executive to ensure that, in future, the NHS will engage in effective dialogue with the people it serves. What does that mean? Effective dialogue and communication is about engaging, openly and transparently, the people and communities who will be affected by a decision. It cannot be done at the end of a process to inform those concerned of the decision that has been taken. It must evolve and involve.
Effective communication is about a process in which information is shared and dialogue is fostered in an attempt to reach common understanding and a shared decision. It is about recognising that when people and communities are involved from the beginning, supported and informed, they do not make irrational decisions. Real dialogue recognises that people and communities can make tough choices and take difficult decisions when they are informed about the issues and feel that they have been part of an inclusive process.
As Margaret Smith said, effective communication has to happen day in, day out, not just when major issues are being dealt with. Under our patients project, we will improve the way in which the NHS communicates with patients, their carers and their families. We will ensure that the NHS engages local communities in a partnership founded on trust, based on a willingness to share information and to consult widely and comprehensively. We will work to create a climate that ensures that NHS staff, patients and their families, and local communities and their elected representatives, are involved and can contribute to the development of the services that are provided by their NHS.
However much we change and improve the culture of consultation and dialogue, we must always remember that we need to improve and change our NHS. We must take our people with us. We must not only inform and consult them, but support and involve them in the development of the services that they use. That is not easy, but it is essential. The work of the Health and Community Care Committee is a welcome contribution to getting it right.
This feels a bit like being in "Dad's Army". We are left to guard the home front while the rest are off at war.
This Parliament first sat a mere five weeks after the NHS in Scotland underwent a huge restructuring process. At the risk of being accused of indulging in consensus politics—don't faint, Susan—I should say that some parts of "Designed to care" met with our approval, not least the abolition of GP fundholding and the removal of that most bizarre policy, the internal market. The SNP also supported the need for transparency and accountability from those who operate trusts and health boards on behalf of the public, who, after all, own the health service.
For as long as I can remember, getting information from health service management has been akin to the drawing of very strong teeth. Since its inception, the health service in general—not only health boards—has operated in a culture of secrecy. For workers in our health service, that has meant a culture of fear: staff afraid to speak out when they know of bad practice; staff afraid to be quoted when things go wrong; and health boards and trusts that feel quite justified in making decisions, if no longer in smoke-filled rooms, at least behind closed doors.
We must put an end to that secrecy culture, which still seems to dominate in health service management. The public, who foot the bill for the health service, must be able to get straight answers to straight questions. For health boards and trusts, that may even mean responding with honesty to questions from the media. In spite of what we have recently been told about the many imperfections of the Scottish press, it is there to inform the public. The time when those who managed the health service could act as if they operated under the Official Secrets Acts has long since passed. Openness and accountability must be the name of the game.
During the Health and Community Care Committee's investigation into the Stracathro hospital petition and, more recently, the committee's consideration of the Stobhill hospital petition, it became clear to us that the culture of secrecy still prevails. Trusts and health boards appear to feel that consulting the public, or, indeed, their own health service staff, is somehow not part of their remit.
I quote from the Brechin Advertiser's submission to the committee, which, in referring to the 700 staff members at Stracathro hospital, stated:
"Time and time again, the recurring theme is one of failure on the part of management to involve or inform staff when proposals are being suggested or decisions taken, with the inevitable result an ever increasing drop in morale".
Is that any way to treat our precious and dedicated health service staff?
Turning to public consultation, I quote from a Stracathro submission from local members John Swinney, Andrew Welsh and Irene McGugan.
"We are also extremely concerned at the lack of consultation which has taken place regarding the proposals . . . It is also evident that TUHT have taken very little notice of the overwhelming opposition from staff, patients and the general public. This failure to consult is indicative of TUHT continuing to take decisions behind closed doors . . . up until October, four months went by without a TUHT board meeting being held in public, at a time when crucial decisions were being made".
As far as Stracathro hospital is concerned, the true story has been one of
"death by a thousand cuts".
As far as the local community is concerned, the trust has said:
"Deil tak the hindmost! on they drive".
I am fond of quoting the Ayrshire bard.
It has become obvious to members of the committee that, while we support fully the human resource strategy, "Towards a new way of working—the plan for managing people in the NHS in Scotland", there has been less than universal compliance by health boards and trusts. There is an urgent need for guidelines to be drawn up for informing, engaging with and consulting staff and the general public on any new proposals by trusts and health boards.
Given the evidence that is emerging, it is now time to address democratic accountability in the national health service in Scotland. In order to address the democratic deficit that is surely a feature of trusts and health boards, it will be essential to consider the membership of those bodies. I contend that, along with executive directors, a health board could surely include representatives from local health care co-operatives and local hospitals as well as locally elected councillors.
That is not to say that the SNP rules out the idea of directly elected health commissioners, which was suggested in Richard Simpson's report and which may well be the most democratic way forward. However, on this day of a somewhat unnecessary by-election, we must recognise the potential for voter fatigue among the electorate. It goes without saying that if we are to include locally elected members on health boards, those members should reflect the percentage of party vote in the local community, which would provide representation for the community as a whole.
I am sure that everyone in this chamber today wants an open, accountable and democratic health service. In this Parliament, we are able to take the necessary steps to change the culture of secrecy that has existed for so long in the health service. We can ensure that health boards and trusts across the country comply with both the terms and the spirit of the strategy laid out in documents such as "Towards a new way of working". We can also address the democratic deficit by ending the quangos that are packed with political appointees, thereby ensuring that the views of the community and those who work in the health service are taken into account when important decisions are made.
The Executive, quite rightly, is fond of talking about a patient-centred health service. I call on ministers to honour that concept by ensuring that the decision-making bodies in the national health service in Scotland are themselves patient-centred.
I am delighted to serve on the Health and Community Care Committee, where we tend to leave our political hats at the door and put health at the centre of the agenda. That is what the people of Scotland expect and I am sure that it is what we will continue to do.
This debate is not just about health. Hardly a week passes in which we do not hear about high-handed practice from quangos and other public organisations. I do not intend to name any of them, but I want to stress that the principles that we are debating today do not relate only to health. They are basic principles for this Parliament and for public sector organisations and quangos throughout Scotland.
I am pleased that Iain Gray acknowledged Conservative initiatives during the 1990s, such as the patients charter. With hindsight, we think that those initiatives did not go far enough. We are still in the process of improving such matters, but I am pleased that it is acknowledged that we recognised the problem during the 1990s.
One of the basic principles of the new Scottish Parliament, as set out in the consultative steering group report, is that
"the Scottish Parliament should be accessible, open, responsive, and develop procedures which make possible a participative approach to the development, consideration and scrutiny of policy and legislation".
I read that out because I think that it is important that this Parliament leads and sets an example for others to follow. Consultation and basic democratic and pluralist principles must be inherent in the way in which we conduct our business in this Parliament.
The CSG report also states that it is essential that
"the culture of openness and accessibility is reflected in the working of the Scottish Executive."
That culture was enhanced by the questioning of the Greater Glasgow Health Board officials by members of the Public Petitions Committee. That was a clear case of scrutiny and accountability, and sent out a clear message that those executives would be held to account by the Parliament.
In our business bulletin every week, there are examples of inclusion of many groups and interests throughout Scotland in the various committees of the Parliament. It is important for the Parliament to provide different channels for consultation, and to review and assess the effectiveness of various approaches.
There is also an important positive role for the media. We may not always like what they say about us or our Parliament but, in a democratic society, we should welcome the basic principle of freedom of speech and the right of everyone to be heard, at national and at local level. Whether views emanate from groups in the chamber, pressure groups, Church leaders, campaigns backed by millionaires or ordinary individual beliefs, principles or value judgments, all have a right to be heard in a free and democratic society.
I endorse the mutual respect approach of Henry McLeish and I tend to ignore the "shut yer mooth, yer lucky to be here" approach of John McAllion. It is not in the spirit of this new Parliament, and it is certainly not a good signal to send out to health boards and trusts, to call the members of the Health and Community Care Committee numpties for expressing our views based on evidence and submissions on the Arbuthnott report. I have heard members of the Executive argue and dismiss views even when we are agreeing with them—causing a rammie in an empty house, as I said previously.
When things go wrong, there is a tendency to blame the Tories for their 18 years of government. When things are right, it is the result of three years of Labour government. When things have gone wrong in the past three years, it is all the media's fault. Unwillingness to accept responsibility is hardly a shining example to health boards and trusts in Scotland.
Is the member suffering from selective amnesia? The Health and Community Care Committee is trying to overturn the secrecy that her party imposed on the national health service.
That is exactly the type of intervention that is not helpful. In the spirit of openness and accountability, we have to accept what each person says, because each person's view is valid.
As long as it is truthful.
Yes, as long as it is truthful. An acknowledgement of the truth would be helpful.
I hope I will get more time if I take interventions.
Indeed.
The member mentioned making a row in an empty house. I think that she is doing quite a good job of making a row in a half-empty house.
I like to cause a rammie whatever house I am in, as long as someone else is there to engage in it.
Six mechanisms of encouraging participation are outlined in the CSG report, but without doubt the most widely used is public petitions. That may be the most appropriate method for some concerns, but it is by no means the most appropriate for all. It may be a simple mechanism, and easy to access, but my concern—and that of the committee—is that without adequate guidelines, the Health and Community Care Committee and the Public Petitions Committee are likely to be bombarded with petitions and our agendas are likely to be hijacked throughout the on-going acute services review.
The arrogant bullying and dismissive approach of the health boards and trusts with regard to Stobhill and Stracathro not only did not harness participation and consultation, but actually set the health service on a warpath with the local communities. That is the tragedy of it all. That approach damaged relations with the communities that those hospitals serve; it also damaged staff morale and caused tremendous resentment and frustration. That is hardly the caring and compassionate service that we expect.
We would probably all endorse the proposal, made at yesterday's Tayside Health Board meeting, that £20,000 be spent on focus groups to gauge local feelings about services and on the setting up of citizens panels. We also know, however, that the answers we get depend very much on the questions that we ask. The outcome also depends on the perception and interpretation of those who are consulting. In other words, they can go through all the motions, but do as they please at the end of the day.
Other members will no doubt point out that at the heart of the evidence that we took on Stracathro, we heard health officers say that they had consulted staff about combining wards, while the staff said that they learned about the proposals in the media. There was undoubtedly a serious lack of partnership.
My final points concern the human resources strategy "Towards a new way of working". There is no doubt that it is an excellent, forward-moving document, but I just do not think that it is clear and specific enough. It is very vague, and does not give adequate guidelines.
In the foreword, Sam Galbraith says that the strategy
"will provide a new framework in which people can realise their potential and feel properly valued."
That is fine. Geoff Scaife says in the introduction that the strategy is intended to provide
"a practical and meaningful way to support people in delivering the objectives of the Health Service."
I was pleased to note in the document that partnership agreements had to be in place by October 1999 and will have to be monitored. Perhaps once those agreements have been put in place and are up and running, and once we can monitor them through the health improvement programmes and trust implementation plans—or HIPs and TIPs—they may prove to be an excellent method.
I do not want to judge something that is very much in its infancy, but over the page, under "What this means", the closest that we get to consultation for the individual is:
"Changes in the working environment which are planned and managed."
For the line manager, the closest we get is:
"To work in partnership with staff and staff representatives."
and for the trust and health board:
"Change will be managed consistently, in partnerships within and outwith the NHS in Scotland."
I acknowledge that the strategy is a move in the right direction, but it is hardly a beacon of democratic accountability, openness and transparency.
Richard Simpson's first-class report and recommendations were highly focused and uniquely appropriate to the circumstances that surround Stobhill. We cannot praise Richard highly enough for this excellent report. The recommendations that he made are not one-size-fits-all for the rest of Scotland. They are specific to Stobhill. There would be different concerns with regard to Stracathro and other hospitals.
My final point is about the structure and accountability of quangos. I hope that we have a further opportunity to address the need for health boards, which cost our NHS £78 million. Their abolition would not only simplify our health service structure, but ensure that the buck stopped at the trusts as they manage and prioritise services in accordance with the management executive's national strategy. There would be no buffer zone, and nowhere for bullying and arrogant officials to hide.
Presiding Officer, I hope that you will consider setting a precedent, whereby those who have acted as reporters to committees have a little latitude when speaking. I will not stretch your patience too far.
I welcome this first ever opportunity to debate the work of the Health and Community Care Committee. It has been said that if this Parliament is to be different from Westminster, that difference will lie in its committee structure and in the relationship among committees, the Parliament and the Scottish Executive.
The central issue in the two reports that are under discussion is accountability. The bedrock of this Parliament's attempt to improve the public's view of the body politic will begin here today. It will be determined by the response of the Executive, part of which we have heard and which is welcome, and of the Scottish establishment to the clear calls for the involvement of civic Scotland in shaping the future of all aspects of our society.
The common theme of the Stracathro and Stobhill petitions was a cry for consultation. In both cases, attempts by trusts and health boards to restrict the flow of information in order to reach difficult decisions failed, with disastrous consequences.
In preparing the Stobhill report, I divided the process of formal consultation into three elements: informing, engagement and consultation. Those will not always occur in sequence, nor will they involve all interested parties at the same time or in the same way, but the whole process must be driven by a commitment to openness and accountability, which is a central aspiration of this Parliament and all of its members.
In deciding its strategy for mentally ill offenders in the west of Scotland, Greater Glasgow Health Board built on a national report and on Scottish guidelines. While drafting its strategy, it involved, engaged and consulted widely with professional staff and their representative organisations, users and patient representatives, and with a large number of partner organisations and individuals. As far as the strategy was concerned, as the report indicated, it was in many ways an example of good practice, but the board and the trusts recognised at that time that the siting of the medium secure unit would be contentious.
What followed was a studied and secretive determination to manage and restrict the flow of information relating to the siting of the medium secure unit, instead of the provision of clear and published plans to inform, engage and consult. The boards thereby forfeited the opportunity to engage with community leaders and with the acute hospital staff leaders to convince them that the best options had been considered and that the conclusions were the right ones, however difficult it would have been to sell the decisions subsequently to the immediate community.
The attempt to manage and prevent the premature leaking of information was ill advised in the Stracathro and Stobhill cases. The results predictably poisoned relationships with the staff and communities. Many more difficult decisions lie ahead for those boards and trusts but, sadly, those decisions will now have to be taken in an atmosphere of mistrust.
Both reports point strongly to a democratic deficit in the composition of trusts and health boards. That deficit impedes the valuable efforts of board members who are appointed to serve our communities. The evident commitment of both ministers to broadening representation is a welcome first step, but we may need to go further.
The imminent announcement of the findings of the acute services reviews across Scotland will test the accountability of our current structures to the limit. If the boards publish only decisions, and are seen as being dragged unwillingly into a process of consultation, the damage to the body politic will be immense.
If we are to emerge from those important reviews with radically modernised health services, as is necessary, which meet the expectations of our communities, boards must publish options rather than decisions. They must put forward detailed plans on the process of informing, engaging and consulting the communities they serve.
Make no mistake: those two petitions and the committee reports that arise from them are no dry academic exercises. They are nothing less than an alarm call to all quangos and to the Scottish Executive. Modernise the process through which our institutions interact with civic Scotland and both society and the institutions will be enriched; fall short of the standards of openness and accountability that we set for ourselves in this Parliament and we will risk the increasing isolation of these institutions and public disenchantment with the political process.
I commend the motion and these reports to Parliament.
Dr Simpson's clear, logical analysis shines a bright light on dark, secretive areas of decision making in Scotland. That is exactly what this Parliament should be doing. I congratulate him on his report on this matter.
The minister, Susan Deacon, has asked for cool, rational debate and avoidance of misinformation by local politicians. That is exactly the attitude with which I started. I was willing to take Tayside Health Board and Tayside University Hospitals NHS Trust's statements in good faith.
Experience has taught me, and the people of Angus, a different lesson. I have heard the theory this morning from Iain Gray, but the people of Angus have had to live through a different reality. The Health and Community Care Committee report clearly shows Tayside health authorities failing to consult properly with NHS staff or the public, against a local back-cloth of past mismanagement and a current revenue deficit of between £12 million and £26 million. The minister has had to send her hit team to Tayside to sort out a massive cumulative failure within the system.
In 1999, the Public Accounts Committee was
"appalled that Angus NHS Trust had 14 out of 16 hospital buildings with a high risk of legionella and that patients and staff were exposed to the risks"
without being informed about those risks. Tayside University Hospitals NHS Trust's proposal to close two wards, cut 30 staff and 50 beds, obviously pre-empted an acute services review, which was due to report 16 days after those cuts were to be implemented.
While Tayside University Hospitals NHS Trust claims that its proposals
"resulted from work done in conjunction with staff at Stracathro Hospital"
that is not how the staff and their union representatives see it:
"There has been no consultation with MSF or the staff concerned before a decision was taken."
Strong opposition from staff, union representatives, patient organisations, the public and professional medical organisations has been ignored. The public have learned about what has been going on through leaks of information, not consultation.
Members of this Parliament had a detailed briefing session on the acute services review only to find, two days later, that ward closures and staff cuts were being implemented. The board and the trust knew that the cuts were taking place and did not mention them. If the minister had been treated in that way, how would she have reacted? The board and the trust apologised, but their actions illustrate their approach to the public, to NHS staff and to the Parliament. It is completely unacceptable. They had not even learned their lesson.
Further cuts in Stracathro services have been decided upon secretly at meetings in February and March, with neither staff nor public representatives being informed. On being found out yet again, Tayside Health Board said, in a letter to me:
"The fact that the staff and patients were not consulted over this matter is certainly unacceptable and those responsible have been brought to task for failing to follow the appropriate procedure."
In fact, it was "those responsible" who wrote that sentence. Taking itself to task is not something with which I would ever trust Tayside Health Board.
Tayside Health Board's latest gambit of focus groups, and now citizens panels, has no long-term accountability or role. It is an insult to the existing health council, which the board has a duty to consult. The focus groups and the citizens panels will contain powerless ad hoc nominees, who will be totally dependent on the information given to them by the health board and the health trust.
The minister is presiding over a dog's breakfast of past and present decisions, taken by an undemocratic system with a history of poor top-level management, of past failure to invest and of a massive current revenue deficit. The minister sacked one health board chairman for less than that. There has to be accountability, transparency, fundamental reform and genuine public consultation. The minister has the power to sort this out, and that is exactly what I hope she will now do. The Parliament should expect no less.
As a member of the Health and Community Care Committee, and having heard the evidence that was presented during the Stracathro inquiry, I am angry that directions from the Executive and the management executive of the national health service in Scotland are not being adhered to.
Sadly, that is not a new experience for employees and users of the national health service in Scotland. My previous employment led to many such confrontations. It is unacceptable that unaccountable and undemocratic health boards and trusts can treat communities and employees in such a manner.
The recent reorganisation of health trusts took away the previous secretive and competitive culture and replaced it with an open, partnership approach to health care provision. However, it is clear that those in health boards and trusts, who we expected to understand the change, themselves need to be trained in the new approach. Sadly, the events at Stracathro and, recently, at Stobhill are common practice. The Parliament needs to embrace—and to ensure—the openness and accountability that is the future of our national health service in Scotland.
Change is a challenge that can be achieved only if all in the process are equal and valued. The accountability process needs to be open and not to take place in isolation of the views of partners and the communities that they serve. A new and visionary review approach should be adopted, to ensure that there is total involvement in practice, not just on paper.
It is evident that health boards have yet to realise that their function in life has changed to that of planning and strategy. They have no responsibility for operational matters such as primary care and, from next year, registration of nursing homes will be removed from their remit. Yet they continue as before, with the same structures and the same dictatorial attitudes. It is no longer acceptable for a trust chairperson to denigrate another trust at a board meeting and think that they can get away with it, as they did in the past.
The trusts and the boards must work in partnership, not in competition. Reorganisation of the boundaries of health boards—here I am, agreeing with Mary Scanlon—is now a necessity, if we are truly to move forward in health care provision.
Recently, the chief executive of the national health service in Scotland, Geoff Scaife, gave evidence on the Scottish Ambulance Service to the Audit Committee. He referred to "territorial health boards". If that is his view, we must ensure that a change takes place soon. To achieve the targets set for the health of Scotland, the challenge must be met head on. I urge the minister to consider carefully the committee's report and the experiences of those who have encountered the attitudes that I have described, and to question whether the current structure can deliver the policies that are needed to improve the health of the people of Scotland in the 21st century.
I congratulate Margaret Smith and the Health and Community Care Committee on the report and on having secured the opportunity to debate the matter in prime parliamentary time.
Margaret Smith said that we are a bit thin on the ground. I can assure her that we are not thin on the ground in another part of Scotland this morning. Those of us who are here today have heard one of the finest speeches in the Parliament—that of Richard Simpson. I hope that Richard's comments percolate into the Executive's thinking on the issues that we are addressing today.
The public have a very simple requirement of public authorities—they want those authorities to be straight with them. People want to be told the truth and to be given clear information on the basis of which they can make their own judgments. I share the experience of my colleagues Andrew Welsh and Irene McGugan, and of others in the Tayside area, in relation to the debate on Stracathro—which employs many of my constituents, although the hospital is in Andrew's constituency—that there is no confidence in the public authorities. Those authorities have not been straight with people who have a right to be dealt with fairly and squarely.
Throughout the exercise, we have been told that the acute services review would review the future of Stracathro hospital. Like Andrew Welsh, some months ago, I was prepared to take that statement at face value. However, we are not foolish people and nor are our constituents. Every month, there are radical changes to the configuration of services at the hospital. There is ample evidence that the acute services review is being prejudged. The acute services review has carried on while various landmark operational decisions have been taken that have reconfigured services. Despite what the minister says, I do not believe that those services will be restored to their previous level.
Compare Stracathro hospital today with what was there when I became an MP three years ago, or when we were elected to the Scottish Parliament a year ago. They are two different hospitals. If the public are to take the process seriously, they must believe that the acute services review is fair and square.
I represent 2,000 square miles of rural Scotland, which, if Stracathro closes, will have no acute service provision. It is not the fault of the people in that area that they live there, and under the Government's white paper, they are entitled to equity of access to acute hospital services. That will be undermined if there is any further question about the future of Stracathro hospital.
Finally, I want to refer to the current climate of the debate on the financial health of the Tayside University Hospitals NHS Trust. Andrew Welsh mentioned that the projected deficit for the trust was in the range of £12 million to £26 million. That is a disgrace.
I accept that there has been a lot of change in the health service, and I admire the health service professionals who have ensured that the delivery of health care has continued while the reconfiguration has been carried out. I support the structure that the Government has put in place, although I am beginning to question the part that some of the bodies, including the health boards, play in the process. Throughout the reconfiguration of services—pre-white paper and post-white paper—Tayside Health Board has been there and has remained intact. Why on earth did one of the trusts in Tayside Health Board run up a deficit of £12 million to £26 million if that health board was properly carrying out its functions? We must have an answer to that question.
I have already said to the minister during question time that I welcome the fact that she has set up a task force on the issue, because something had to be done. I am glad that she has acknowledged the depth of the problem, because it is causing unease among my constituents. We have to ask questions about the performance of a health board that has allowed this to happen in one of the primary bodies from which it commissions health care.
Margaret Smith's point that the clinical voices will always be heard has been well understood in the debate. However, we have to be straight with people and say that those voices are being heard in a particular financial context that affects the clinical advice that is given. The public must be told that straight. In the debate that we are having in Tayside, the public are not hearing that from the health board or from health trusts.
Although located near Brechin in Angus, Stracathro hospital has for many years served the people of the Mearns, in my constituency of West Aberdeenshire and Kincardine. Stracathro lies at the junction of three constituencies, and we have already heard from John Swinney and Andrew Welsh.
I am only too well aware of the depth of concern for the future of the hospital. I have spoken at packed local meetings; last September, together with other MSPs who are here today, I addressed a public rally outside the hospital where there was a crowd of more than 1,500 very concerned people.
As the Health and Community Care Committee said in its report on the petition submitted by the staff action committee at Stracathro, the case has clear implications for the exact way in which future public consultations should—or, rather, should not—be conducted by local health boards. Many people in the Mearns believe that the public consultation sessions that have been conducted so far have been flawed.
It is an uncanny coincidence that, only yesterday, I received a fax from Tayside Health Board that contained a press release announcing that the board planned to establish a citizens panel, made up of members of the public from across Angus, Perthshire and Dundee. It claimed that that would give the public an equal voice to that of health professionals and managers in the acute services review. Although that development is welcome to the people who are served by Stracathro hospital, it might be too late to restore the confidence that has already been lost in Tayside Health Board's decision-making process.
No mention is made in the health board's press release of the participation in the proposed citizens panel of the people of the Mearns. That simply will not do. The people whom I represent are certainly not satisfied with the health board's action so far, and it seems to me that that press release is the latest example of ill-thought-out and hasty actions that are designed to placate critics—especially those in this chamber. I hope that it has noticed that it has not succeeded.
The actions of the board have not impressed me, and I can assure members that the people whom I represent and who use the hospital remain unimpressed by the whole consultation process. Why oh why did the board fail to agree to involve the Brechin patients association and—more particularly for my constituents—why did it not hold public consultation meetings for people in the Mearns? Whether true or not, the impression that has developed in the Mearns is that the review is meaningless and is a fait accompli in regard to Stracathro. The taking of operational decisions—such as combining wards, suspending surgeons and transferring operations—appears to prejudge the review and sends all the wrong signals about the credibility of the review as it affects the hospital and the people whom it serves.
What is the wider message for health boards in conducting consultations? It is this: they must not act in such a way as to be seen to prejudice the outcome of reviews, either in terms of employee relations, or by saying no to public meetings. The simple lesson of Stracathro is that, once something has been tarred with the brush of being a fait accompli, it is hard, if not impossible, to get rid of that image.
I welcome the committee's report, but I note that—although in its conclusions it recognised the fact that the board failed to hold public consultation meetings in the Mearns—in its recommendations it said:
"The committee strongly urge the Trust and the Board to maximise efforts to consult timeously all levels of staff at Stracathro and the public in Angus now and at all stages of the Acute Services Review."
I am critical of the health board, but the Health and Community Care Committee should remember that Stracathro hospital serves more than the people of Angus. I have criticised the board for forgetting about the people whom I represent in the Mearns. Has the Health and Community Care Committee also overlooked them?
On a positive note, I thank Margaret Smith for her kind words about the Public Petitions Committee. As the convener of that committee, I am happy to bask in the glory of her comments. I happen to think that it is the best wee committee in the Parliament because it has no agenda of its own—its agenda is dictated by the people of Scotland who petition Parliament. Many of the Parliament's other committees show due respect to the petitions that are sent to the Parliament, as we have heard in the debate.
On a less positive note, I would like to tell Mary Scanlon that what I said was that members of the Opposition should shut up about how to squeeze money out of Scottish taxpayers to fund their party political offices. They should, instead, concentrate on the issues that affect Scottish people, such as that which we are debating today. I am glad to hear Opposition members address the issue and I would like to reassure Mary Scanlon that I will defend to the death her right to spout odious, right-wing Thatcherite rubbish, as she does in Parliament. This is a democracy in which she has every right to do that.
We are debating a motion that asks us to note the lack of accountability of health boards and trusts, especially in Tayside, but also throughout Scotland. I am happy to agree with the motion. I note what the minister said about boards now holding their meetings in public, about openness and about new codes of accountability and routes of accountability through ministers to the Parliament. All those systems are being reviewed.
I have been a long-time supporter of the proposals that were developed by Maria Fyfe MP, when she was the shadow health spokesperson for the Scottish Labour party. She recommended that one third of the membership of health boards and the boards of trusts should be elected by the local communities; that one third should be nominated and elected by trade unions in the health service; and that one third should consist of local elected councillors or nominees of the Scottish health minister. Those recommendations were never implemented and I do not know why. I do not see, however, why—as we are approaching Easter—they cannot be resurrected. We should again examine ways in which to introduce democratic accountability to the operation of the national health service.
The report highlights many of the things that are wrong in the health service in Tayside, especially in relation to the future of Stracathro hospital. It highlights the threat of closure that has hung over the hospital for 20 years under successive Governments. It highlights the fact that the staff at the hospital and the public in Angus are convinced that decisions about their health service are being taken above their heads by unelected and, therefore, unaccountable board members, first in the former Angus NHS Trust and now in the Tayside University Hospitals NHS Trust and throughout that time by the health board. If we are honest, we will accept that all those bodies are ultimately accountable to the NHS management executive in Edinburgh and to ministers—formerly those at Westminster and now those in this Parliament. We are all tarred with the same brush.
There is a great deal of genuine concern. I recognise the concerns about operational decisions that are being implemented now, but which appear to undermine the viability of Stracathro hospital at a time when a crucial acute services review is being conducted in Tayside. The Parliament must take those concerns on board, but we must also understand that they are symptoms of the much deeper problems that affect the health service in Tayside and throughout Scotland.
All three of the trusts that existed before Tayside University Hospitals NHS Trust left significant operating deficits, which the new trust must do something about. When will those responsible for those deficits be held to account? How will they be held to account? That is a major problem which affects the health service.
Does Mr McAllion accept that Tayside Health Board has been there throughout the process, and that it was not doing anything about Stracathro in its overall management of health care in Tayside?
Of course I accept that—but Tayside Health Board has had to work within the financial constraints that are placed on it by this Parliament and which were previously placed on it by the Westminster Parliament.
The fact is that this Parliament passed the budget with 59 votes for it, none against and 46 abstentions and every one of the bodies involved operates within the budget's confines. Alternatives were available; however, no MSP suggested that we use our tax-varying powers to set up a special fund that would allow the NHS to implement the changes more slowly. We must all accept responsibility for the situation; a hunt for scapegoats is not the way to resolve anything. The next time we set a budget in this Parliament, we should be clear about its implications.
Consultation consists of two parts: talking to people and listening to what they say. That simple fact has largely eluded most health authorities for years, because even when the requirement to consult has been honoured, it seems not to have been a requirement to pay any attention to the outcomes.
The time is long overdue to find mechanisms to make health authorities accountable and to ensure that meaningful consultation takes place continuously, not only when major changes are planned. Nowhere is that more urgently required than in Tayside, where consultation with the people of Angus has established beyond any doubt that the primary concern is the provision of locally available health services.
I am well aware that there have been intermittent concerns about the future of Stracathro hospital for many years, because I have lived all my life within 15 miles of the place. A noticeable decline began again about two years ago, when consultants and other staff left—and were not replaced—either because they felt that the hospital's future was at risk or because of increased pressure of work. Then a projected £12 million deficit for the current financial year was announced and substantial and irreversible changes to staffing and ward configurations were implemented. All that has happened during a wide-ranging acute services review.
Throughout that time, there has been no evidence of open, truthful or timely communication with members of staff, and certainly no recognition of the concerns of thousands of Tayside residents who attended public meetings and signed petitions to highlight the erosion of acute services at Stracathro hospital, pending the acute services review and without prior consultation.
The staff and patient representatives should be congratulated on focusing national attention on those issues and on bringing the matter to the attention of the Health and Community Care Committee. It is one of the best examples of a local issue with national implications being addressed since the advent of devolution.
When public confidence in Tayside Health Board and Tayside University Hospitals NHS Trust was all but non-existent, Susan Deacon finally responded to persistent concerns expressed by MSPs and others and appointed a task force. However, it remains to be seen whether there will be any effort to redress the failure of the health board and the trust to manage their affairs properly; to protect the interests of the people of Tayside; to ensure that local health services are properly accessible; and to ensure that there are no further blunt cost-cutting exercises that will diminish services further and put people out of work.
Forgive me for being cynical, but the timing of yesterday's press announcement that Tayside Health Board will be the first to have a citizens panel smacks of trying to draw attention away from the realities of the situation to date in Tayside, where substantial concerns of MSPs and the community about the future of health services in the area have not been eased. Those concerns have been too long expressed and too long ignored.
We need a proper structure in which local health councils, community councils, local authorities and—where they exist—local patient organisations and carers groups all have a role to play. That might help to ensure that not only potential savings for health authorities but patients' needs are addressed in any proposal for change. Above all else, provision of care should be patient-driven not budget-driven, and should meet the needs of the community through properly implemented consultation procedures.
I welcome the opportunity to exchange horror stories about Stracathro and Greater Glasgow Health Board. Primarily, I want to touch on the issue of Stobhill hospital and the similarities between the situation there and at Stracathro.
The Stobhill petition raises serious concerns about consultation with local staff. Ministerial guidance in the past—I understand that it is still the same—has been that changes in health care should be clinically led. None of us wants to move away from that and, indeed, Margaret Smith touched on that in her speech this morning. It appals me, therefore, that the medical staff at Stobhill hospital were not consulted on the proposal for the first medium secure unit in Scotland. As at Stracathro, the staff were advised of the proposals through the media. That is appalling in the 21st century. Staff want to be involved in health care and want their specialist knowledge to be taken on board.
I want also to mention the bad practices employed by Greater Glasgow Health Board, in particular in relation to consultation with the local community. Iain Gray quite rightly pointed out that we must enter into meaningful consultation. Why then were people advised in a question-and- answer session that the only consultation that would take place between Greater Glasgow Health Board and the local community on the secure unit would be through the statutory planning process? How meaningful is that?
Is it meaningful consultation when members of the local community have to drag the health board kicking and screaming to public meetings to relay the fact that they want to be involved? Is it meaningful consultation when the local health trust chief executive feels that it is inappropriate for her to attend public meetings? Of course not. Dr Simpson's report on the situation at Stobhill hospital has shown the need for condemnation of the practices used on that occasion.
The lack of statutory guidelines has been noted, but does not remove the moral obligation on health boards to engage with the local public when public concerns in local areas are identified. Injustices have clearly taken place against the local community at Stobhill. It is not good enough to say that we will learn from the experience and move on; we must correct those injustices, particularly those experienced by the local community at Stobhill. Health boards must clean up the mess that they have left. Andrew Welsh described the situation at Stracathro as a dog's breakfast. I would use similar words to describe the situation at Stobhill.
The atmosphere among the local public makes the acute services review difficult. Richard Simpson touched on that. How can the acute services review genuinely move forward, if consultation on the first secure unit in Scotland was so poor?
Finally, I want to touch on the issue of health councils, which was mentioned by the convener of the Health and Community Care Committee. It is appalling that health boards should interview applicants for health councils, which is what happened in Greater Glasgow Health Board. We must ensure that health councils are wholly independent.
I commend the motion.
This debate is about public consultation and accountability, but the structure of the health service has been mentioned more than once. I make a strong and passionate plea for us to leave the structure alone, at least for a number of years. We need to allow the health service to apply itself to providing health services—after a succession of reorganisations and reconfigurations in recent years that have meant that a huge amount of energy has had to be diverted to managing change, not services.
We hear about the democratic deficit in the NHS. It has been argued that health board and health trust board members should be elected and that health councils, like community councils, should be elected; that people should have a direct say in who is managing services and spending money on their behalf; that directors of public services should be directly accountable to the people who use and pay for those services.
There is an argument that appointing boards allows the selection of people who can bring appropriate or useful skills to the job. It is the intention that the current system should cast the net more widely and that it should be made more transparent. However, the electorate can be just as discerning. We should not underestimate its ability to elect the right people for the job, as against the need to select on the electorate's behalf.
Let us not kid ourselves that people are falling over themselves to be given the opportunity to correct the democratic deficit. Most people are not that excited about elections—strange as that may seem in the context of today. They find them an intrusion into their lives. They are asked to consider issues, evaluate candidates and make decisions. It is much easier to decline the responsibility and then complain later. We should overcome resistance to having to vote for health boards, health trust boards and health councils. People should be involved in how their services are provided and in how their money is spent.
There can be resistance from the public at large and from members of a work force to becoming involved in consultation exercises. It is hard work to have to think about issues, to consider alternatives and to make difficult decisions. It is right to work hard to overcome resistance to that, and to persuade ordinary people, staff at all levels and patients to get involved, and to persuade them that they have a valuable—even invaluable—contribution to make.
Having involved people, we must value their contribution and give it proper weight and consideration. To achieve genuine interest and involvement, we have to play fair with people. They have to be given full, complete information, and they have to be trusted by means of completely open disclosure of all the issues, problems, constraints and possibilities. That trust must then be honoured by consultees, who should treat responsibly information that is given to them. If a number of options are under consideration, they must be seriously debated. Ideas and options can be floated but, if they can be demonstrated to be unworkable or undesirable for any or many reasons, they should be allowed to fall.
There can be a number of answers to any question, none of which is exclusively right or wrong. A way forward must sometimes be chosen as a balance of perceived outcomes.
A major barrier to that sort of openness and real accountability is the way in which difficult and complex issues can be reported by the media. Oversimplification of issues and an occasional refusal to distinguish between suggestions being floated for discussion and firm proposals can be terminally damaging to the process.
Whatever the difficulties and however high the barriers, we should aspire to a much more open, involving and accountable culture in all public services, including the health service. The Scottish Parliament is receptive to petitions from the Scottish people and responds to them. Through the work of its committees, the Parliament is making an effective contribution towards that aspiration.
Changing the culture of any organisation is a long, slow process, and requires to be worked at continuously. We have all—the public, politicians, patients and professionals—taken only the first stumbling steps along a very long road, but we should keep at it.
I want to address the problems of management. It is clear from what we have heard today that it is the management at Stracathro and Stobhill that has been at fault. It is bad management that is leading to the lack of trust, to the lack of consultation and to the lack of preparation.
Throughout history, great armies have ground to a halt or failed in their tasks because of a lack of communication and the absence of clear, consulted plans. Bad communication leads to a loss of flexibility and inefficient use of time. It provides the quickest way for a soldier to lose trust in his officer. A lack of consultation leaves soldiers feeling worthless and makes rumours set in like a plague. That will sound familiar to anyone who has visited the Stracathro area. The patients and the community have been plagued by rumour, lack of consultation and bad management.
History always judged the generals for their failures. Health boards must learn the same lesson. The health service can be compared to an army—both are large, multi-level bodies working in specialist fields with specialised employees. Both are vital, work under pressure and try to make politicians' plans work on a shoestring. Health staff, doctors and patients look to the health boards for leadership. Clear plans are expected, consultation demanded and honesty required when blame is apportioned. In return, higher salaries are paid and trust is returned.
In the cases of Stracathro and Stobhill, it is clear that the officer level—the board management—has failed. While I disagree with many of the Government's policies on health, I can see that those in the know failed to consult in a structured and clear way. Little thought had been given in the planning process to review or the making of changes. Indeed, my inquiries to a number of health boards about their consultation frameworks have met with blank responses. A plan of action cannot be deviated from if it does not exist.
If we have learned one thing from the debate, it is that health boards and hospital trusts should draw up agreed, structured plans for reviews, closures or expansions. Management should involve the patient, the resident, the doctor and the nurse in formulating those plans. Only then will trust be maintained. Last night, I was faxed the news that Tayside Health Board has created a wonderful new citizens panel. That is good news, but it is slightly like shutting the stable door after the horse has bolted. I wonder whether the panel was set up because of this debate and because a task force has gone in to deal with the obvious failings in the health board's management.
Battles are won only when a team gets behind the plan of decision. Politicians who exploit rumour and hysteria only add to the problems. They do not contribute an iota to the patient's case. Politicians should not stir situations, but guide them. No one wants to say this, but someone should: consultation does not always mean majority decision making. It means taking points on board and thinking aloud before coming to a decision. In the end, however, decisions must be made and they will not please everyone. The aim to provide the best health service must be paramount. Unlike the situation in this Parliament, the health service is about management and the policy makers—it cannot be a Chinese parliament.
Our party does not oppose more accountability for managers and boards. Good management should have nothing to fear—unlike bad management. I take on board John McAllion's point—I believe that the people who have caused the problems in Stracathro should not be allowed to get away with it. They must be held accountable for the faults that they encourage.
I ask the minister to find ways to insert elected representatives into the system and to re-examine the membership of those boards. I ask him to monitor and guide the national health service and public feeling. The Scottish Parliament provides us with an opportunity better to focus our policy and scrutiny. Let us not waste the opportunity better to scrutinise the health service.
I thank Mr Wallace for his speech, although I was convinced for the first half of it that he was about to announce the invasion of France rather than talk about the NHS. That would be an interesting diversion from the Tories' European policy.
I am not known for being overly sensitive, but I am feeling somewhat bruised as a result of Margaret Smith's remarks and those of the other people to whom I have spoken this morning. The first person I met today was a friend whom I have not seen for six months. He told me that I am fat. I came into the chamber to be told that I was no use to man nor beast, and when I turned round to Mr Swinney for solace, he told me that I had grey hair at the back of my head.
Although I am having a bad day, the Parliament is having a good day. I associate myself with what Richard Simpson said about the balance of power in this Parliament, and believe that it is important to put today's debate in the appropriate context. This Parliament is about spreading the power, trying to get away from an over-mighty Executive and about decision-makings being passed down. The fact that we can have a committee-inspired debate on a consensual and constructive basis is important. Richard Simpson, the golden boy of today's debate, is not very popular on the Health and Community Care Committee, as the next person who has to act as a reporter will have such a ridiculously hard act to follow that no one is keen to take on that role.
Some people have suggested that the fact that the report exposes major weaknesses in the NHS is a bad thing. I suggest that the Parliament is finally working. The fact that we are opening the dark recesses and discussing the problems openly is a positive sign of how far the Parliament has come.
It is relatively easy to sum up a debate such as this, as there has not been a great deal of disagreement. The central theme has been the difference between the theory of what we want in place—the theory of what has already been suggested in various Government documents, going back many years—and the practice on the ground. There is no lack of paperwork—no lack of thought or of proposals—and it is worth revisiting "Designed to care" which the minister mentioned. Under the section that details "Responsiveness to the public", it says:
"To redesign services from the perspective of patients—and to reflect this in all aspects of health service planning—requires finding out what patients and communities want; and consulting them over proposals for change."
The Government talks about requiring health boards
"to undertake thorough and imaginative consultation".
The contrast with what we are hearing today could not be greater. We have heard about the proposals for focus groups, citizens juries and survey methods. All the proposals exist, but they have not been implemented. That is an issue that the Parliament and the Executive should address.
The debate is not about blame or putting the boot into the Executive, but I would like it to address one point. Further on in the same section of "Designed to care" we are told that a key feature of the management executive's performance management of boards and trusts will be their ability to move towards that level of accountability. That returns us to the point that Margaret Smith made at the beginning of the debate. Until that level of accountability is built into the review process, we cannot have confidence that there will be progress.
Anyone who has read the report will be conscious of the threat of closure that has been hanging over Stracathro for 20 years. They will also be aware of the failure to involve the patients association, the failure to have public meetings in Montrose and Mearns, the failure to consult staff at all levels—a point that Margaret Jamieson made today and throughout the committee process—and the fact that the whole process was driven and dictated by leaks and innuendo that undermined the morale of staff and motivation in the health service. That is a damning indictment of the health board and of the health trust that is involved.
Andrew Welsh made a useful, powerful and clear contribution to the debate by pointing out that lessons have perhaps not been learned from Stracathro and that there is an immediate problem to be resolved. I urge the Executive to take that point on board. He also turned to one of the central contentions of the report: that the acute services review was pre-empted. The decision was not being postponed, to be made rationally; it looked as though a decision had already been made, which could do nothing but disfranchise the people who were involved in the process.
John Swinney raised a wider issue, on the role of health boards. The fact that the health board was involved throughout the process means that it is utterly culpable for the current position. Parliament must examine the role health boards should play, particularly—in the era of devolution—with the arrival of local health care co-operatives and the desire to have decisions made more locally. I wonder how long health boards will continue in their present format.
I do not want to repeat what Richard Simpson says about Stobhill in his report, or what he has said today. The key point of both concerns the stage of the process at which people become involved. People must be involved at the beginning of the process and all the way through. There must be full and meaningful consultation, not simply lip service or the occasional passing of information. There must be a real dialogue.
A third example of the same problem, at Oban hospital, was brought to the Public Petitions Committee this week. The petition has been passed to the Health and Community Care Committee. I represent that area and there is enormous community unrest about what is happening. The chief executive of the acute trust admitted at a public meeting that he does not have the faintest clue what it is like to live, work and need a health service in a rural area. It is not surprising that the current structure does not give people confidence that their concerns are listened to.
I do not wish to pre-empt the Health and Community Care Committee's discussions, but the main point raised by that example is whether the current structures aid or hinder lines of communication. The health board covers a partly rural and partly urban area. Perhaps the health board structure inhibits the flow of information and the decision-making process. If that is the case it is a major challenge for our committee and for the Parliament.
Kay Ullrich laid down a challenge this morning. We now have various reports and we are all acutely aware of the problem. Positive suggestions have been made—by the Executive, by the Health and Community Care Committee and by other members—but we need action. We need to feel that the debate will be followed through, not forgotten. In an era of devolution, the clear message from the Parliament must be that accountability and participation is as much a part of the Scottish NHS as it is intrinsic to the very existence of the Parliament.
Everybody is understandably concerned about an aspect of democracy—elections. Today's debate reminds us that the new democracy we have created in Scotland goes far wider than that. Mary Scanlon referred to the central concepts for this Parliament of accountability and participation by the public, laid down by the consultative steering group. Today, we are debating the extension of those principles to all the local governing bodies in Scotland.
The petitions came to the Health and Community Care Committee through the Public Petitions Committee, which again is a new feature of the Parliament and allows the public to have a new input into policy making. I have not taken part in such a debate at Westminster.
My colleagues on the Health and Community Care Committee and I were concerned not to pre-empt local decisions about the acute services review. As many members have said, there are hard choices to be made and most of us, I am sure, believe that services must be redesigned, sometimes in controversial ways. The Health and Community Care Committee therefore focused on the processes that are undertaken by health boards and trusts in making decisions. The key concepts, mentioned in the motion, are accountability and consultation.
Accountability goes in two directions. I am glad that ministers are seeking to ensure that health boards and trusts are more accountable upwards, to central Government and its priorities. Today we have concentrated more on their downward accountability to local populations. Richard Simpson was right to say that accountability begins centrally with a flow of information. That has often not been the case; both Margaret Smith and Kay Ullrich referred to the "secret service" that has been common.
Accountability means visible policy. It means local bodies justifying what they are doing and the possibility of local people challenging decisions. Beyond that, some members have suggested we need to introduce sanctions so that the people who make decisions can be got rid of. For that reason, some people want members of health boards to be elected. I do not think the Health and Community Care Committee has a particular view on that, although it has said that it should be actively considered.
Some of the central recommendations of the Health and Community Care Committee reports on Stobhill and Stracathro concern consultation. A clear recommendation of both reports was that staff consultation, as outlined in the human resources strategy, should be implemented. As Iain Gray said, we are at the beginning of a process, but it is important that the new culture of the health service be adopted by local health bodies. I was pleased that Iain Gray said that the accountability review would take that on board. We now have the Scottish partnership forum at a national level and, as he reminded us, local forums are being set up.
Margaret Smith made the central point that there is a lack of clear guidance on effective consultation, especially in relation to new services. I am glad that Iain Gray said that the Executive is developing new guidance on consultation. Many people in Scotland are very cynical about consultation and feel that it is often just a formality and that a health board or trust goes through the motions of holding public meetings but does not take on board anything that is said.
The concept of permeability is perhaps more useful than that of consultation. Permeability contains the idea that bodies have to be open to what local people say to them. It is important that, as Richard Simpson said, consultations give options rather than decisions, so that local people feel that they have a say and are not being consulted only formally. It is important that health boards and trusts should be permeable and undertake genuine consultation and that local people should feel that they can be involved in decision making in local health care co-operatives, which are new bodies that have been set up under the new health structures. The Executive's quality programmes should also incorporate the views of patients.
That principle was flagged up in "Designed to care" at the beginning of the health reforms in 1997. It is very important that it be put into practice so that patients and the public feel that they have a say in the health decisions that affect them personally and in the broader health decisions at a local level.
The Health and Community Care Committee also raised the issue of appointments to health councils. In the past, health councils have been the voice of patients at a local level. If patients become involved more generally at every level of the health service, the role of health councils may have to change. The Health and Community Care Committee suggests that appointments to health councils should be examined. At the moment, members of health councils are the appointees of health boards. There may need to be a radical restructuring of health councils as part of the process of opening up the health service.
The third principle of the new NHS democracy—the first two are accountability and consultation, or permeability—is redress. People must feel that they can get redress when something goes wrong and that they can get satisfaction from bodies with which they are dissatisfied. The Health and Community Care Committee has considered that matter. The NHS complaints procedure is being reviewed. It is important that more independence be introduced into that procedure. The Health and Community Care Committee looks forward to being involved in further discussions about that matter.
Today's debate has illustrated that the Scottish Parliament and its committees offer a new channel of redress. In the past, the people served by Stracathro or Stobhill would have felt that nothing more could be done after they had campaigned. I am cheered because this debate has shown that the Parliament is a new arena in which people's concerns can be listened to. It was important that the Health and Community Care Committee took up the massive concern about Stracathro and Stobhill and considered the general issues that arose from the petitions.
There will be many other acute services reviews at local level over the next few months. It is important that conclusions are drawn from the reports that have been debated this morning and that clear guidance is given to the NHS management executive, so that the Health and Community Care Committee does not have to receive many more petitions complaining about the lack of consultation and the failure of local accountability in a particular area.
I hope that the Health and Community Care Committee has made a useful contribution to this area of debate and shown that in the new Scottish Parliament there is a system of power sharing that allows committees to influence the development of policy and to ensure that improvements are made as a matter of urgency by the Executive.