National Health Service (Future Needs)
Good morning. The first item of business is a debate on the implications of the Kerr report for the future needs of the national health service. I call Margo MacDonald to open the debate.
Good morning to you, Presiding Officer, and to those members who have got here in time. As one would expect from business in the independents' allocation of time, this morning's debate will not be used to bash Lewis Macdonald or to allow Lewis Macdonald to bash anybody else. We have had enough bashing without thought in here, so we will be thinking instead about the implications of Professor David Kerr's report for the NHS in Scotland.
I believe the report to be a good analysis of the principal requirements of the NHS in the 21st century. When it was published, some commentators talked down the importance and quality of "Building a Health Service Fit for the Future". Some said that we had heard most of the report's observations and recommendations before, which seemed to me to be a case of "Never mind the quality, feel the width."
Of course, it is true that we have heard clinicians, academics and health workers in general expounding the need for a particular specialism to be located in one hospital because that is the only way in which the necessary throughput of patients can be achieved to enable surgical teams to develop their expertise to the highest level possible. However, the Kerr report is the first of its kind to remind us implicitly but quite firmly and consistently that there will be trade-offs in the redesign of health services delivery systems.
To paraphrase Professor Kerr, if patients want to be admitted to hospital as soon as possible after diagnosis, within the timescale intimated to them, and to leave after as short a stay as is compatible with a good recovery, they—that is us—will have to take more responsibility for their own health, fitness and sense of well-being. In principle, that seems a fair enough trade-off to me, but such a refocused approach will not just swing into place without the appropriate planning procedures or without excellent communication of ideas and objectives to health workers and their potential patients, before policies are signed and sealed. There must also be practical demonstrations from the Executive of how trade-offs can work in the interests of all parts of the Scottish community.
It is important that the Executive should take the lead in demonstrating that. To give an example of what I mean by the Executive taking the lead in changing our perceptions about how the NHS can best nurture good health, as opposed to cure bad health, I commend Andy Kerr for his attendance at and support for the launch of the Long-Term Conditions Alliance Scotland a couple of days ago. That new charity comprises voluntary organisations that have been campaigning for years on single conditions, representing people who live with diabetes, epilepsy, asthma, post-polio syndrome, lymphoedema, the after-effects of stroke, colitis, Parkinson's disease and many other conditions, some of which are life-threatening and some of which are not but which, nevertheless, are extremely debilitating and, if not managed properly, can easily act as catalysts for the development of other conditions and illnesses, including mental illness, resulting in misery for the sufferer and additional cost to the NHS.
The minister has wisely pump-primed that new charity because if it is to contribute to the redesign of services as a genuine partner with health boards and social work and housing departments, it will need the money to engage staff who are equal to the task. Thought and energy are required to maximise the return on the resources committed by the Executive and the money raised by the various charities in the umbrella alliance of long-term conditions campaigns. I know, as I am sure other members will, of umpteen campaigning groups and charities that are forced to spend a disproportionate amount of their time and energy on fundraising. Although I am not advancing a case for throwing even more money at organisations such as the Long-Term Conditions Alliance Scotland—because I am well aware that we are now spending twice what we were spending when the Parliament came into being—I urge the minister to get together now with the voluntary organisations that might be expected to underpin the collective care in the community of people with the sort of conditions that I have referred to and to deliver much of the information and education that will enable sufferers to manage their conditions and achieve their personal optimum level of good health. It is a waste of the expertise of sufferers, their carers and the volunteers who support them—to say nothing of the diminished quality of support for sufferers of long-term conditions—if too much time is spent on trying to raise money. There is a balance to be struck and I do not think that we have got it quite right.
In Edinburgh, there is a prototype of the sort of provision that utilises the energy and imagination of volunteers and appropriate services. The Minister for Health and Community Care has visited the Fala Court health initiative with me. I hope that Lewis Macdonald has heard of it, and he is welcome to visit it too. That sort of service points to the future of achieving what the Kerr report says we should be attempting to achieve for the NHS.
At the heart of the conclusions of the Kerr report are the aspirations of promoting local access to services and balancing local delivery with the need to have centres of excellence that provide high-quality, modern, specialist care. I do not think that that is a definition that anyone could disagree with if they believe in a health service that respects the desire of individuals to be treated as close to home as possible but which is clinically safe. Although the Kerr report gave a great deal of thought to the balance between locally available health services and the need for some specialist care to be delivered in a limited number of locations, it did not give definitive guidance on which services should be located at a local or a specialist location.
That is now the issue that bedevils a number of health boards as they try to use the conclusions of the Kerr report to justify the centralisation of services in the community, because it is easy to argue in different circumstances and in different parts of the country that one specific service should be locally based and another should be at a more central location. In certain parts of the country, the public are being asked to support the centralisation of certain health services that have been made available locally by health boards, with the Kerr report being used as justification. That is exactly the type of lazy management that the Government has been prepared to accept from health boards around the country. Members of the public are being asked to accept a route to centralisation by Executive-appointed health boards that is being resisted by numerous members of this Parliament, many of whom support the Executive. The situation is so serious that the Home Secretary, among his many other problems and challenges to date, has had to take to the streets to defend local health services from the centralising acts of a health board appointed by Labour ministers in the Scottish Executive.
In my view, those members of Parliament and members of the public are right to challenge the centralising tendencies of the health boards.
Do Mr Swinney's general comments on the import of the Kerr report mean that his party would never support the specialisation of services or the delivery of specialised services at a prime site?
I made it clear in my opening remarks that anybody who believes that we should have a health service that is clinically safe must accept that there will be specialisation at certain locations. The issue that concerns me is the use of the Kerr report as an excuse for centralisation by lazy health boards. I will go on to say more about the health board in my locality, which is a good example of a health board that is resisting the temptation to centralise, but in the course of my remarks I will illustrate to the minister exactly what I mean by lazy health boards that use the Kerr report as an excuse. I believe that the decisions to centralise have been driven more by a desire to save money and to avoid changing the medical profession's working practices than by a desire to deliver the optimum service to patients within the resources available.
I represent a constituency that has had to put up with a lazy health board that is prepared to take decisions on that basis. Thankfully, that has changed since the appointment of Peter Bates as chairman of NHS Tayside. When I was elected to Parliament, NHS Tayside was running down Stracathro hospital. My colleague Andrew Welsh and I repeatedly said that it would be a death by 1,000 cuts for that hospital. The drive was to centralise services at Ninewells hospital in Dundee and to reduce levels of service for patients in Angus. After a huge and broadly supported local campaign we changed the mind of NHS Tayside. The board listened, it thought out of the box and it challenged working practices in the medical profession. Today, more patients than ever before are being treated at Stracathro hospital. There is to be an expansion of services and patients can barely get near the hospital for the queue of Government ministers visiting to see how it can be done.
Perth royal infirmary faced similar threats. The health board removed consultant-led maternity care and tried to initiate a process of removing other key services. The community resisted and the health board came up with a virtual acute hospital model, which was achieved by linking Ninewells hospital and Perth royal infirmary. The objective was to expand the services available in Perth by changing working practices. We will hold the health board to that objective.
In the context of the local delivery of care, my colleague Christine Grahame will address the threat to local cottage hospitals in the Borders. The health board in my area has maintained and is investing in a range of cottage hospitals at Blairgowrie, Aberfeldy and Pitlochry. It sees cottage hospitals as providing a valuable level of care a step down, which can take the strain off acute hospitals. Why do boards in other parts of the country not see such hospitals as the valuable assets that they are?
The one gripe that I have about the centralisation of services relates to the out-of-hours service. The minister will be aware of my concerns about what is happening in the very remote areas of my constituency, where the fact that GP practices are being allowed to opt out is resulting in a diminished level of out-of-hours care. That is an example of the centralisation of services in rural areas; many other examples in more urban communities also concern many members. It is right to resist centralisation, to challenge health boards and to seek to get the right balance between local and specialist care, which many health boards have failed to do.
The Kerr report reflects a consensus in Scotland that the national health service needs to change, but the question is how it should change.
The report recognises that most patient care is best provided at local level. Primary care services should supply the care and support needed to enable patients to cope with their chronic health problems at home or in their local communities and should encourage them to take responsibility for their own health. Such an approach reduces demand for secondary care and relieves pressure on hospital and specialist services.
Most people want the focus to be on local care. It is accepted that there are compelling arguments for highly specialised services to be available in a few centres of excellence, but there is a clear demand for as much health care as is reasonably practical to be provided locally.
However, if local delivery is to work, it will involve a great deal of workforce planning. People will have to get used to being seen by the practice team and not only by their GP; many allied health professionals may be involved in the care of a patient.
Recruitment is already a problem. GPs are hard to come by in some parts of Scotland. There are global shortages of specialists in a number of clinical areas, and there will be an escalating need for already scarce specialist nurses and various allied health professionals. There will be a need to train generalists as well as specialists and GPs are being encouraged to develop special skills, for example in orthopaedics, dermatology and minor surgery.
Health boards are taking their first steps towards change. They are not all doing it at the same pace or in the same way. There are tensions between boards that are trying to rationalise services through amalgamation and centralisation and patients who want to retain their familiar local facilities.
Kerr says that the NHS in Scotland can meet the challenge of change by building a new relationship of partnership and trust with the public, but that is already being threatened by the proposed closure or downgrading of local hospitals. People do not accept that having to travel to a distant accident and emergency department because their local facility has gone represents progress.
The mums in Aboyne in Aberdeenshire will fight to the end to keep their midwife-run maternity unit, because they value the care that they receive in their community. Rather than accept closure because the local delivery rate is low, they want actively to promote their unit, as was done successfully at the Montrose unit in Angus, which is now a thriving unit that nobody would dream of closing. People want the local hospital to diversify and perhaps to provide chemotherapy, care for the elderly or minor surgery, but not at the cost of losing the maternity unit.
Compromises must be made. Not every facility can be available everywhere, but local input and co-operation are vital if Kerr's proposals are to be implemented successfully.
There is not time in such a short debate to deal with all the current issues of concern. The establishment and operation of the new community health partnerships seem to be variable, according to anecdotal evidence. Some CHPs appear to be working better than others. I would welcome an update on the matter from the minister.
There are still concerns that, whatever the minister has said to the contrary, the centralisation of specialist services will lead to the downgrading of units such as Aberdeen's neurosurgical unit.
As John Swinney said, in many areas there are serious problems with out-of-hours provision of primary care. The care that patients desire is often not available. Workforce issues are far from being resolved.
I want a health service in Scotland that is clearly focused on the needs of patients and is accountable to them, in which the primary care team, led by GPs—who are best placed to advise patients—determines, in conjunction with patients, their journey of care within the NHS. The service would cease to be a monopoly provider, which is centrally driven and developed according to directives and targets. Instead, it would become a service that reacts to the needs and demands of its patients. If the NHS is to work in the real interests of patients, power must be given to them and to the professionals rather than to politicians. Sadly, we are a long way from achieving that.
The Scottish Liberal Democrats welcomed the publication of the Kerr report. In years to come, it will be remembered as a significant landmark in the history of the NHS in Scotland. The Executive's response, "Delivering for Health", set the agenda for implementing the Kerr report. "Delivering for Health" is set against the background of the near doubling of the NHS budget from £4.6 billion in 1999 to £8.8 billion in 2005. The effective use of that large increase in the budget is critical to achieving the vision set out in the Kerr report and "Delivering for Health". It is critical because it is unlikely that the next six years will see another such increase in the NHS budget.
"Delivering for Health" set out four main priorities for reshaping the NHS: to make it as local as possible; to achieve systematic support for people with long-term conditions; to reduce health inequalities; and to actively manage hospital admissions.
On the first—making the NHS as local or as close to home as we can—we must ensure that NHS boards and local authorities take a new approach to infrastructure and buildings. It is self-evident that not every town and village can have one of everything. However, shared facilities and the delivery of health services in community settings allow services to be provided close to home. There are good examples throughout Scotland of shared facilities. There are new or improved buildings where community health services are delivered alongside social work and social care, and from where allied voluntary bodies offer their expertise in the community.
The model of sharing premises for care raises another issue, which is that patients can fall between two budgets. Can the member suggest a solution to that problem?
It is interesting that Mr Swinney talked about health boards being lazy. That may be his experience in his area, but I think that it is more about mindset. The point is to ensure that people understand that there are huge benefits to be had from sharing facilities and, where necessary, pooling the labour force in social care and health services. There is a great deal to do.
I will return to my theme, which is that there is no reason why the NHS should not go beyond that and—where it is sensible to do so—share facilities with the private sector. For example, where we need to replace or renovate a community hospital and there is scant local nursing home provision, there is clearly an impetus for having a shared facility. Indeed, I advocated exactly that in my constituency, where in Coldstream and Jedburgh the community hospitals are in need of renewal and nursing home provision is lacking and needed. There are clear opportunities to develop an innovative approach.
Will the member give way?
Yes.
In supporting Mr Robson's line of argument, I suggest that he might want to investigate a proposal in Pitlochry in my constituency to construct, for the first time ever, a GP practice, a local community hospital and nursing home provision on a single new site. That is a welcome model of how to proceed.
That is precisely the kind of innovative solution that many local health and social work professionals would advocate and which I am sure can provide answers for the future. There is no doubt that sharing facilities leads to much more and better local services.
I am part of a group of people in Edinburgh who are trying to bring together medical GP services, associated complementary services, social work services and all the things that we have talked about and which the Kerr report talks about. I hope that Euan Robson agrees with me that we must address the point that David Davidson raised, which is that funding streams often get in the way of good ideas.
The Executive could assist with funding streams by ensuring that innovative approaches are promoted.
We are not good at sharing best practice in Scotland. Mr Swinney mentioned an example of good practice and there are others in Ayrshire and Lanarkshire. I believe that if we were better at sharing good practice—in which there is a role for the Executive—we could ensure that the vision in the Kerr report is brought to reality.
On long-term care, we must take into account important workforce development in certain areas. I believe that there are greater opportunities to share training and to dovetail social care and health care skills to provide a more effective service for people in Scotland.
There is no doubt that in future the Kerr report will be regarded as a turning point for the better in the long history of the NHS in Scotland. In many ways, the report is visionary and, as such, it has caused controversy and debate in many areas of the NHS. The attempts at rationalisation are probably the most contentious issue currently in the NHS in Scotland. Many people regard that approach as missing the first dominant issue that Professor Kerr identified in the foreword to the report—addressed to the Minister for Health and Community Care, Andy Kerr, on 15 May 2005—which was
"Maintaining high quality services locally".
In many areas, such as Lanarkshire, the local health boards seem to have missed that important point.
Lanarkshire NHS Board's cost-saving decision on which accident and emergency unit to retain certainly cuts across the principle of maintaining high-quality services locally. However, I am confident that in the final analysis our minister, Andy Kerr, will show the wisdom of Solomon and will come up with a solution that will allay the fears of the people of Lanarkshire. That will possibly be done by retaining the A and E units in Wishaw, East Kilbride and Monklands. It has not been shown that anything less than the existing set-up would be as good. Not retaining those units would mean that high-quality local services would not be maintained, which would be against the spirit and the intention of the Kerr report.
Care in the community is a key element of the Kerr report. I wish the minister every success in that area because it involves treating people in their own homes, wherever possible. Obviously, that will mean a massive increase in the number of ancillary workers who are required. Care in the community services would alleviate the sad situation of elderly people who live alone all too often being placed in care homes and then being shocked to find that their home has been sold to pay for their residential care. To have their homes stolen by an uncaring state is no way to treat hard-working senior citizens who have contributed to the welfare of our country all their lives. That intolerable situation cannot be allowed to continue. We should remember that the NHS was set up to care for all from the cradle to the grave and not from the cradle to the care home.
Despite that major glitch, are things improving in the NHS in Scotland? The simple answer is a definite yes and the proof of that is the increasing life expectancy across the country, except for in a couple of black spots where it is attributable to basic deprivation. Statisticians forecast that by the end of the century more than 1 million people in the country will be over 100 years old. Longevity is the ultimate measure of the success of the NHS. That pleases me because it will increase my party's scope to increase its membership.
The Kerr report is a consensual document. As I have stated before, health should be taken out of the political arena and every party should propose its positive ideas. They should do so not for party-political gain, which happens too often in this place, but for the overall good of the NHS and for the ultimate good health of the people of Scotland.
That is why the Scottish Senior Citizens Unity Party will invariably support Andy Kerr as he strives to improve the health of Scotland's population. He is being attacked on the issue of targets by the media and by MSPs from other parties. However, targets are set with the best of intentions. They are laudable and it is superb when they are achieved. Instead of the usual yah-boo confrontation in this place, let us hear in the future—and starting from today—constructive ideas being advanced by all those who claim that they could do better.
First, I declare an interest: I am a member of the British Medical Association.
I very much welcome this debate and do so, perhaps slightly unusually, not primarily for the chance to express my point of view but to hear what the minister will say. When the Kerr report was published almost exactly a year ago there was a cross-party welcome for it. There was a feeling that here was a way of taking forward the NHS and that the report's recommendations would be implemented rather than just sit on a shelf as previous reports had done, such as the report on the acute services review. Rather than debate the report's merits, which we are pretty much agreed on, we want to hear that progress is being made towards implementing the report's recommendations.
In answer to a question on 25 May last year, the minister said:
"I am happy to support the proposal for a network of rural hospitals and the education and training infrastructure that will support it".—[Official Report, 25 May 2005; c 17165.]
I would very much welcome an update on progress towards that because for those of us who represent rural areas the idea of rural general hospitals was one of the most welcome things in the report. It was regarded as an answer to what we had been asking for all this time: an area between the highly specialised centres, which we all agree are necessary for some conditions, and delivering care as near to people as possible.
The report also mentioned community hospitals. When we debated the Kerr report when it came out, I was not clear whether the minister envisaged that as simply a rebranding of existing cottage hospitals or an expanded network of community hospitals. I am still not clear about that and I would like an update on the matter. On the technological side of bringing medicine closer to the people, I would like an update on our progress on telemedicine, which is important in remote and rural areas.
We have all agreed that local delivery is the right approach and that an appropriate network of professionals should support it. We are talking about not just doctors but specialist nurses and specialist allied health professionals. I still think that there are not enough specialist nurses for epilepsy, asthma, diabetes and so on. Such professionals are much valued by the patients who are lucky enough to have access to them, but they are grossly overstretched.
I will give a local example of that—we are all trotting out such examples. The cystic fibrosis physiotherapist who covers the whole of the Highlands, Western Isles and west Grampian area works 25 hours a week. When the post was established in 1988, her caseload was 27 but, because people with cystic fibrosis now live a lot longer, it is now 46. That professional, whose work is hugely necessary in treating cystic fibrosis and keeping people with it healthy, is trying to cover an area the size of Belgium on 25 hours a week. Financial constraints mean that the health board cannot increase her hours. I do not believe that that is acceptable. It is just one example; I am sure that members have others.
A pledge was made to engage early with local people about what was being delivered. I would like to know whether that is happening, what has changed in how the NHS engages with communities and how far-reaching the engagement is. Some people will share my reservations about some of the target-driven approaches in the NHS. I have heard that in Highland, where there is a shortage of orthodontists, the locum orthodontists are being encouraged to make senior referrals to keep to the waiting-time targets for such referrals rather than for initiating treatment. The permanent post-holders will come back to a huge backlog of patients who need treatment, which has been piling up because the locums have not been treating them. I belong to a party that often insists that the Executive should set targets in certain areas but, although targets can be valuable in some areas, they can have a distorting effect in others.
I do not have time to cover health inequalities and the need for good demographic information. One of the points in the Kerr report—and the Executive's response to it—was that good case finding might prevent some acute admissions. That is fine up to a point, but it is dangerous to assume that we will not need acute beds as a result, in the same way as it would be unsafe to assume that because people are living longer and staying healthy longer, local authorities might not have to provide residential care.
On health promotion, I draw to members' attention a motion that I lodged just after the new year. It was an excellent motion—some members might remember it and some might have signed up—because the words were not mine but the BMA's. The motion says a lot about what we need to do to build a healthy Scotland, which is not just about delivering health care. It states:
"That the Parliament agrees with Dr Peter Terry, chairman of the British Medical Association in Scotland, that a long-term public health strategy can be effective only if there is a co-ordinated approach across all ministerial portfolios; notes that decisions taken in other policy areas have a significant bearing on public health; agrees on the need to develop synergistic policies and cross-departmental co-operation, and calls on the Scottish Executive to introduce a system of routine health impact assessments to be applied to all policies and legislation."
That is crucial. We assess the impact of all legislation on equal opportunities and human rights; we should also consider its impact on health.
I will finish with a statistic that members might have noticed on the excellent play display in the garden lobby. For every 80 acres of golf course in Scotland, there is 1 acre of children's play area. We are not really building a Scotland in which it is possible to grow up healthy. We should consider not just health delivery, but the kind of Scotland that we have.
I welcome this opportunity to discuss the challenges that we face in providing the health service that people in Scotland will need in the future.
We spend a disproportionate amount of time discussing hospitals, given that 90 per cent of health care is delivered in a community setting. I crave members' indulgence, because I want to discuss a local building that is causing concern. Perhaps we should give more consideration to the range of services that are delivered in GP surgeries and health centres. In Linlithgow, there are two strong pressures on the health centre. First, there are increasing patient numbers, given the growing population that has resulted from new housing. Secondly, there is a desire to offer a wider range of preventive health services within the health centre. I have attended yoga classes for babies and support groups for people with multiple sclerosis—I am sure that other members have done such things in their constituencies. Those are small examples of what goes on within the health centre, which means that it is outgrowing its existing premises. However, given the developments that are taking place in the town, it is difficult to find a site for a new facility. Options are being considered, but they will cost money and they need to be fit for purpose.
I acknowledge the substantial funding of £50 million that the Executive has made available for new, modern health centres. However, many people are competing for those funds and I hope that the minister understands that a growing population cannot wait—people need the service now.
As I said, the health service should be seen as more than buildings. The Kerr report stated clearly that the health improvement agenda was crucial. We need to establish good eating habits, which can be learned at home and supplemented in schools. We need to keep active, whether by exercising at the local gym or walking more regularly—even if we just walk around the shops. We need to care for our mental health, perhaps by having a job that we enjoy, which raises our self-esteem, or by socialising with family and friends. All those measures can help us to stay healthy and none of them requires a hospital or a health centre. However, the Scottish Executive has a role to play, which Eleanor Scott mentioned, in joining up the services that we provide to ensure that there is a framework within which to deliver them.
When health problems arise, we need a range of health staff to meet our needs. Much of our previous discussion has concentrated on doctors and consultants in particular, and the figures are encouraging. In answer to a question from the Scottish National Party health spokesperson, the minister was able to confirm that the number of consultants in the Lothian NHS Board area rose from 536 in 1997 to 685 in 2005. However, the figures also need to show consultants' specialties. The national workforce planning framework will be essential to ensure full coverage of all specialties.
The Kerr report acknowledged the role of other health workers and the wider roles that could and should be developing for them. I found the Royal College of Nursing's briefing for the debate interesting and agree that nurses could and should play a wider role in the community in health education and preventive health, and that their skills in more complex areas should be developed. Other allied health professionals can also offer support. Podiatrists, physiotherapists and occupational therapists provide services in local, and even home, settings. They can support older people with physical and mental health problems, which keeps them out of our hospitals.
I welcome the development of community health partnerships. The CHP in West Lothian, although still relatively new, is already having an impact in joining up services. The buck can no longer be passed between social care and health care. That is particularly important in addressing the needs of an older population, who, with minimal support, could remain in their own homes for longer, which the majority of them say that they wish to do. New technology is also helping people to stay in their homes, so we need to continue to invest in it.
Given the variety of health professionals who work in the community, I would be interested to know how far we have moved in developing protocols to allow health workers other than GPs to take self-referrals and, if necessary, to refer cases back to GPs.
I am sorry that we do not have more time for the debate, because I think that it will play an important part in developing a new, modern system that will address people's needs, not just through hospitals and doctors, but through a range of health facilities and professionals who work in our communities.
Like Eleanor Scott, I want to know what has happened since the Kerr report was published a year ago. I remind members of some of the report's recommendations, which were that high-quality services should be maintained locally; that local needs and expectations should be met; that options for change should be developed with people, not for them; and—this one is close to my heart—that the Scottish Executive should review its guidance on public consultation, with a view to promoting best practice.
A number of weeks ago, NHS Greater Glasgow and Clyde held a workshop about the new sick kids hospital, which I and others were not told about. However, being the type of person that I am, I found out about it and managed to go along. In light of my experience, perhaps the Executive should review its guidance on public consultation.
On the maintenance of local high-quality services, I point out that Glasgow has gone from having five accident and emergency departments to having only two. Given the threat to Monklands hospital, which I mentioned last week, and the state of the services in Argyll and Clyde, I have to ask what kind of local services we can expect in Glasgow. When people have to travel three quarters of the way around Glasgow and beyond to get to what should be local services, I do not think that local needs and expectations are being met. How would having only two maternity hospitals in Glasgow meet local needs and expectations? It is proposed that the new site for maternity and sick kids services should be at the Southern general hospital, but it is in dire need of modernisation. Operating theatres are closing down there because of modernisation. Maternity wards are being closed because they need refurbished and fixed—they are falling down. How can people be comfortable with that situation? I would like the minister to look into that particular issue.
Margo MacDonald and Eleanor Scott mentioned the training of staff. That is an important point. I recognise the fact that staff have to be trained to do outreach work. However, at the NHS Greater Glasgow and Clyde meeting that I referred to, certain fears were raised regarding specialised paediatric nurses. Obviously, if facilities are closing, parents will themselves diagnose their children, deciding whether to take them to the sick kids hospital across the river, an ambulatory care and diagnostic centre or local services—of course, we should bear in mind the fact that the ACADs and local services will not be open at night.
When I asked a question about the specialist training of paediatric nurses, I was told that that was being looked at. It is an important point and I would like the minister to tell us whether the Executive has any figures regarding the training of staff. Like Mary Mulligan, I think that the Kerr report's recommendations in that regard were important. We do not seem to have any monitoring or evaluation of any of those aspects of the Kerr report.
The Kerr report mentioned the fact that we have to look after people in deprived areas. However, I do not see any more outreach work being done in the deprived areas that I represent, such as Drumchapel. There is no evidence of extra nurses, doctors and health workers being able to do outreach work in those areas. I would like the minister to tell us whether there are any updated figures on outreach work or recommendations about how we can get the health professionals to work in the areas that I mentioned, so that people there get the services that they deserve.
The Kerr report says that services should be localised to meet people's needs. I do not believe that closing down three hospitals and having only two maternity hospitals is meeting people's local needs in Glasgow. I would like the minister to revisit that issue.
Although I do not want to focus on them, it is worth noting the issues that brought about the Kerr report. Issues such as the European working time directive, consultants' specialisms and subspecialisms, junior doctors' hours and training and accreditation have brought us politicians to a point at which, like it or not, we have to make decisions to ensure that a much-loved, respected and valued institution continues in a modern form in Scotland.
Although it is not a panacea, Professor Kerr's report gives us a course of treatment for the ills that affect today's national health service and offers a way forward that could revolutionise the health service and make it more responsive, effective and efficient.
The key innovation in Kerr's report is the idea that services should be designed to suit need and that there should not be Berlin wall-style health board boundaries. As I have argued repeatedly, the case for designing services to meet need is strengthened by the fact that quality health services still tend to be most readily available to those who need them least. We are still beset by the strange one-size-fits-all approach. Out-of-date funding formulas and notional equal access to general practitioners has resulted in healthy, affluent areas having the same concentration of doctors as do the poorest pockets of public health. That results in poor sick people having less time with GPs; being less likely to be referred to a consultant; being more likely to be seen in an overburdened, single-doctor practice; being more likely to be seen by a younger doctor who has never been in a deprived community before in his life; and being more likely to die younger. The report of the Kerr subgroup on health inequalities confirms that that approach has seen the gap between rich and poor grow rather than shrink.
I do not disagree with a word that Duncan McNeil has said. However, does he agree that it is not the health service's policies or strategies that have brought about the situation that he describes, but the economic situation? If we are talking about tackling the inequalities in health, we must address that as well.
Yes, but today we are discussing the health service's role. If we wanted, we could discuss the community regeneration fund, the central heating programme, the warm deal and the massive investment that there has been in early years and other stages of education. We are making progress in that regard but, this morning, we are discussing the responsibilities of the health service with regard to that agenda. That is why I slightly disagree with the British Medical Association, which promotes the interests of consultant doctors in relation to subspecialisms, reduced hours and less contact with patients. The BMA lectures us about our responsibilities, but it needs to face up to its own responsibilities.
Last month, I had the opportunity to put some of those points to the chief medical officer for Scotland, Dr Harry Burns, who was attending a meeting of the Health Committee to discuss the Kerr subgroup's findings. To his credit—this underlines how the debate has matured and moved on—Dr Burns said:
"If we are to tackle the increased prevalence of disease in deprived communities, we must match that increased prevalence with an increased number of GPs."—[Official Report, Health Committee, 18 April 2006; c 2725.]
Implementing the Kerr report properly means giving most help to those most in need and using resources to maximum effect. However, if we are serious about doing that, bold choices must be made. We cannot continue to pour money into making the healthiest healthier while my constituents are dying in their 60s—indeed, too many of them do not even make it that far. This week, members will have seen figures highlighting the persistently poor infant mortality rates in some deprived areas.
Further—and this will be difficult for some people to hear because of the positions that they have held—implementing the Kerr report properly requires us to address the complete disgrace that is the Arbuthnott formula. I understand that the work on the review of the Arbuthnott formula has been delayed—given the sensitivity around the issue of redistribution, I suppose that that is not too surprising. I await the outcome of those discussions with interest.
I repeat: if we are serious about tackling health inequalities in Scotland, bold decisions need to be taken.
Earlier this week, NHS Forth Valley made an important announcement about plans for a new hospital in Larbert. That modern, state-of-the-art hospital will cost £300 million and will have about 800 in-patient and day-patient spaces, providing a range of acute services for people in the health board's area.
I warmly welcome the fact that the plans are on schedule for work on the site to begin early next year and for the new hospital to open in 2009. The design of the hospital looks good and it will be located in an excellent environment, in the spacious grounds of the former Royal Scottish national hospital.
However, I am not happy about certain aspects of the health board's announcement. I am concerned about the fact that many of the employees in the new hospital, including porters, catering staff and cleaning staff, will be employed by a private company rather than by NHS Forth Valley. At present, the dedicated NHS employees in those positions give such a quality of service that they have won national awards for catering and cleaning standards. I fail to see how a private company won the contract for that work unless it is intent on cutting wages or cutting the number of employees. That could threaten the standard of patient care, which is dependent on staff morale and the employees' team spirit.
I am also concerned about the apparent assumption that the new hospital will be a private finance initiative project. Last Friday, I and some parliamentary colleagues met board members and officials of NHS Forth Valley. We were told that a decision on the method of funding the hospital will not be taken until later this year, yet according to the press release that the health board issued on Tuesday of this week, Mr Richard Weston, the managing director of Equion, said:
"We are delighted to have been awarded this project, which is the largest PFI hospital in Scotland."
That company or consortium—whatever we call it—has a dodgy track record in PFI projects, including alleged profiteering from the refinancing of a hospital south of the border. Past experience shows that PFI does not represent best value for money. The number and cost of PFI projects could be a millstone around the necks of future generations of taxpayers for many years.
The NHS was founded to serve the needs of the people, not to line the pockets of profiteers. Yes, we need new, modern hospitals for the 21st century, but surely there is a better way of financing the building programme in the interests of patients, NHS employees and taxpayers. I therefore urge the Scottish Executive to think again.
I begin by reminding members how many people work for the health service throughout the United Kingdom. I believe that it has more than 1 million employees. For our ministers, both at the United Kingdom level and here in Scotland, managing the process must be like turning the Titanic around on a sixpence.
As my colleague Mary Mulligan said, 90 per cent of health care is delivered at the primary care level. The challenge is to move health care services even further into primary care rather than simply continuing to think that services can be delivered only in hospitals. I remind Sandra White, in particular, of that point. Her mindset seems to be that we can deliver services only in the hospital environment. There are some essential services that must be delivered in hospitals, but we must open our minds to ways in which we can deliver more services in local communities.
I welcome Margo MacDonald's comments on the Long-Term Conditions Alliance Scotland. Like her and other members, I have worked with a number of organisations—including the Skin Care Campaign and organisations that are concerned with musculoskeletal conditions, rheumatology and osteoporosis—and tried to help them to highlight chronic conditions. We need to pay more attention to those organisations' concerns. That challenge is in the Kerr report and it also comes across in the briefings that were sent to us by the Royal College of Nursing and Age Concern. In dealing with chronic conditions, demographic changes are the biggest challenge. We need to think about how the reform of prescription charges is going to pan out, given that the minister's consultation on the matter is coming to an end.
Eleanor Scott said that we should focus on the delivery of services rather than simply debating the Kerr report. I will highlight a few things that are happening in Fife. When I picked up a publication from the National Rheumatoid Arthritis Society recently—I promise that I had no hand in preparing it—I was delighted to learn that it cited Fife NHS Board as the best example of good practice in the UK. The board was commended for the way in which it delivers rheumatoid arthritis services much closer to people in the community. I am sure that the minister and others will also be delighted to hear that. We need to think about taking more services out of the hospital environment and into local communities. Throughout Fife, the aim has been to deliver services as close as possible to people's homes.
Another example of good practice that was highlighted in the Kerr report is the Leith medical centre, which is a model urban community hospital that could be replicated elsewhere. In my constituency, at Dalgety Bay and Inverkeithing, I have what is perhaps the biggest general practitioner practice in Scotland, which is striving to deliver services more locally, outwith the hospital environment. Simple procedures for which people previously had to go to hospital are now carried out locally.
There is yet more progress—I am not ashamed of mentioning all these examples of good practice. In the Kerr report, the workforce planning inquiry and elsewhere we heard about how many of our students were ending up in Manchester rather than here in Scotland. A lot of our students were lost to Scotland forever because they were trained in Manchester, but I am delighted that we now have a really good set-up. Medical students no longer automatically go to Manchester but are trained in our own backyard at the Randolph Wemyss memorial hospital in the Buckhaven and Methil area.
Fife is in the vanguard of delivering digital imaging services. When people go for X-ray treatment they can now access the service not just locally, in Fife, but—
I accept that Fife is fabulous, but given that there are GP surgeries, walk-in services at hospitals and complementary services, how are the funding streams straightened out?
In Fife, we are addressing that problem. The social work department and the health board have a joint approach and a joint agenda for the future in Fife. They are tackling the issue of the funding streams. I was interested to hear what is happening in other areas. It seems so straightforward. We get the people who have the budgets, sit them down and tackle the issues. There is a lot to learn from the Fife example.
Technology is vital. I do not often cite things that have been done by members on the Opposition benches, but yesterday I attended a very good briefing that Shona Robison—who is not here this morning—organised on a new machine for cancer treatment called CyberKnife. Apparently, there is not a single CyberKnife machine in the UK, even though there are such machines in the Netherlands and throughout Europe. I am told that the best example of their use is in northern Italy. I appeal to Scottish and UK ministers to seek a briefing on CyberKnife. However, I am delighted that Ninewells hospital in Dundee is leading the way on new photodynamic therapy treatments for cancer.
Coming back to Fife, our catering service has been returned in house and is no longer provided by external contractors. It is tremendous that we have that in-house service.
Eleanor Scott made a good point about play improving people's health. There are more swimming pools in Paris than in the whole of Scotland. Joined-up working by the Scottish Executive is essential. We need many more swimming pools because the therapy of being in a swimming pool is superb for elderly people, people with mobility problems and people with chronic conditions. I am sure that Dennis Canavan, as convener of the cross-party group on sports, would agree that we need a great expansion in the number of swimming pools throughout Scotland.
In my contributions to previous debates on the Kerr report, I acknowledged that most, if not all, of us can agree with the prescription that Kerr gives us for the reconfiguration of the NHS in Scotland. We want to move away from a reactive system that is geared up to provide a crisis intervention service to a system that prevents medical crises from arising in the first place. The provision of continuing care in the community will be the key to such a transformation, particularly for the growing number and proportion of elderly patients.
How we get from where we are to where we want to go is fraught with difficulties, not least of which is the poor performance of health boards in making the case for change and bringing patient and public opinion with them as they develop proposals. The Kerr report highlights the need to meet patient expectations and build public trust, but the public are losing confidence in the NHS because of creeping centralisation and specialisation. People are willing to travel for highly specialised surgery, but they want core services, such as accident and emergency services, to be close to home. A and E units are the safety nets in a crisis intervention system and their proposed closure is bound to cause public alarm.
The consultation exercise on NHS Ayrshire and Arran's review of emergency and unscheduled care presented only variations of a preferred option, all of which entailed the closure of Ayr hospital's specialised A and E unit. NHS Ayrshire and Arran's approach offered a model of how not to conduct a consultation exercise, although the board claimed to have followed to the letter the Executive's guidelines on public consultation. If that was so, the guidelines are deeply defective and utterly fail to ensure public engagement with the change process. Even if one accepts the need to centralise specialised A and E services, what justification can there be for not presenting an option for centralisation of such services at Ayr hospital, which was deemed feasible in the options appraisal exercise? Given Ayrshire's geography, that option would minimise inconvenience to the public. I urge the minister to consider the mess that NHS Ayrshire and Arran has made of the public consultation. The matter must be revisited if we are to restore a semblance of public confidence that the future of the NHS is in safe hands.
The minister should focus on how to deliver community-based services before he approves radical surgery to specialised A and E units. If public support for the direction of travel that Kerr advocates is to be generated, the Executive must take time to build capacity for home care for the elderly, community casualty units and the extra specialist staff that the NHS needs. The minister should not allow health boards to force him to make hasty decisions for which a heavy political price must surely be paid.
The debate has been interesting, because members have promoted ideas and set challenges for the Executive, which I think was Margo MacDonald's intention when she started her speech. She said that people must take personal responsibility for their health, because they are on a lifetime's journey. However, if people are to do that, they must have education. Parents must understand how to educate their children so that they are tooled up to assume that responsibility.
I am worried about long-term alliances, because we had a little difficulty with the Scottish cancer coalition. The coalition was a great idea and most MSPs turned up for its launch, but it has been pretty quiet on the ground and I wonder whether it enjoys much independence. There must be a joined-up approach to using the voluntary sector to supplement or develop services, which might mean that the voluntary sector should be given contracts to do its work. Such an approach might enable standards to be set but would require reasonable funding.
John Swinney, who is today's substitute striker for the Scottish National Party, mentioned a couple of interesting issues, of which clinical safety was the most important, because clinical safety should be the basis on which services are designed. In that regard, A and E services should be designed on the basis not of geography but of the time that it takes to reach a unit. The odds of someone to the north of Stirling who is in a critical condition getting an ambulance all the way to Larbert in time are pretty remote. We must ensure that A and E planning takes account of the emergency nature of A and E.
John Swinney talked about the misuse of centralisation. The minister appoints health board chairs, so a variation in performance is very much at the minister's door and should be dealt with by him.
Nanette Milne talked about workforce planning and recruitment and retention. She said that we need clinical generalists, which is a matter that Dr Jean Turner has raised in the past.
We support CHPs, but they must be regarded as joined-up organisations and not just a group of people who sit round a table, each with their own budget. As I said to Euan Robson, what happens if a patient falls between two budgets? We must be brave and amalgamate budgets, to eliminate the nonsense of double handling and ensure that patients do not fall through the gap.
When Malcolm Chisholm was the Minister for Health and Community Care, I told him that the debate should be about who can do what, rather than who does what. We must consider upskilling different health professionals. Susan Deacon supported an increased role for pharmacists. Specialist nurses can also take on increased roles, because most nurses have degrees that include a specialism. Such nurses are an important asset, because doctors do not have to do everything.
We must ensure that we have a good network of local general hospitals, which are key to the whole approach—that is a major theme of the Kerr report. If there is to be specialisation, we must decide what should be specialised, where specialised services should be available and to what standards such services should operate.
Adam Ingram said that it will take time to change the attitudes of the public and patients to the redesign of services, so the minister should not quickly chop off services with which people are familiar. Does David Davidson agree?
Yes. However, the key to that is consideration of what we mean by consultation. If we want the public to come on board and play their part, ministers and health boards must listen and there must be reasonable consultation.
In the case of Ayr hospital's A and E unit, in which John Scott has been heavily involved, some 55,000 people signed a petition and 5,000 went on a march, which indicates people's anger and frustration that, despite the consultation, apparently nobody had paid a blind bit of notice to their angst. Similar situations have arisen in relation to maternity services at Aboyne hospital and Fraserburgh hospital. There is disunity between thinking in the health service and public opinion and we must bridge the gap. That will require leadership.
Eleanor Scott talked about removing silos. During many debates in the Scottish Parliament, people have talked at length about the roles of education, social work and health services, yet the ministers with those portfolios seem to operate in silos—I say "seem" because that is the perception; if joint working is going on behind the scenes, we should tell the public about it.
Like other members, I attended yesterday's presentation on the CyberKnife. We should consider such innovations, but they cost money.
Duncan McNeil was right to talk about the support that is offered to different parts of society. Health inequalities exist, but much can be dealt with by education and a will to move away from a sticking-plaster service towards an approach that is based on health promotion and disease prevention.
The independent MSPs asked for ideas and I am sure that many people have ideas. We do not use statistics properly. Because we do not gather or make available the right statistics, we do not do proper forward planning on staffing and other matters. If we do not plan, our approach can only be piecemeal.
If we are to move forward, we must take the public with us. There is a place for the consumer and the potential consumer in the redesign of health services, which affect everyone's family. I welcome the tone of the debate. We must ensure that we plan efficient, focused services that can be delivered. The public must feel that they have ownership of such services.
This has been an interesting debate. My remarks will jump around a bit because I want to deal with what several members have said.
I could not agree more with what Margo MacDonald said about people taking more responsibility for their fitness and health. However, in Penicuik, for example, the leisure centre is under threat of closure. That example links into what has been said about silo mentalities. Last night, a meeting was attended by 150 people—young and elderly—who were desperate to keep the centre open. The centre helps to keep them fit, keep them out of trouble and keep their minds alert. Such things are happening on the ground as a result of local authority cuts. The Parliament provides substantial budgets to local authorities, so members must consider such matters. Local authorities are making cuts, leisure centres are being closed and there will be an impact on the health programme. Cross-cutting work is therefore not happening.
I will deal with John Swinney's interesting remarks later. I will visit the Tayside model—I wish that I had done so before—and take Borders NHS Board representatives with me. The ethos at Hay Lodge hospital in Peebles is to combine a GP unit, nursing beds and a cottage hospital, but it is a pity that such an approach is not taken elsewhere. I will touch on what is happening in Jedburgh and Coldstream later.
Euan Robson, Margo MacDonald, David Davidson, Helen Eadie and others mentioned issues to do with silo mentalities. I do not know how the cycle can be broken, although we have all said that doing so would be common sense. Social work departments, health boards and local authorities defend their budgets, but people who have been assessed as being able to return to their communities are stuck in hospital beds that they cannot leave because social work departments do not have enough money to allow them to do so. By the time those departments have money, people become more institutionalised, have to be reassessed and end up back at the end of a queue. Human misery and costs result. We have been saying that for seven years.
Does Christine Grahame welcome the approach of the CHP in West Lothian, which has brought together council and health board funding? One officer is responsible for overseeing matters, so no one can say that something is not their responsibility, and people are not kept in hospitals when that is inappropriate.
I welcome progress that is made anywhere. I cannot speak about what happens in the Lothians, but that approach is not being taken elsewhere—it is certainly not being taken in the Borders, where there is still competition for budgets. There is a patchy approach.
I am sorry that I got lost with John Swinburne's remarks on septuagenarians. I do not know whether he was directing them at me, although I do not think that he was.
I agree with Eleanor Scott. There are issues to do with having a target-driven approach, which distorts requirements on the ground—health professionals, too, are conceding that.
I got lost with Mary Mulligan's images of babies in the lotus position. I thought that they could adopt that position anyway.
Sandra White referred to an important point that the Kerr report makes. The report states that we must
"develop options for change with people, not for them, starting from the patient experience and engaging the public early on to develop solutions rather than have them respond to pre-determined plans conceived by the professionals."
I am afraid that the experience of many people who have gone to NHS board meetings is that the latter approach has been taken. They get the feeling that decisions have been made, that consultation is cosmetic and that people are not going with the grain of public feeling.
Does the member agree that consultation does not necessarily mean saying yes to everything and that part of the problem is how to track changes and make transparent to the public what changes there have been as a consequence of consultations? To my knowledge, that has never been done.
That is another issue. However, in respect of the Borders, I knew ages ago that the hospitals in Jedburgh and Coldstream were set for closure and that the NHS board was simply working out how to present the case. That is the reality. People are not silly—everyone else involved knew that too. Such an approach is not in the spirit of the Kerr report and does not deliver what people want. I agree that people cannot have everything that they want, but if we go with the grain and listen to people, we will find that they sometimes have jolly good ideas about what should happen in their communities.
Duncan McNeil rightly talked about issues that have impacted on costs to the health service. Contractual and legal imperatives, whether we like them or not, have had an impact on costs. However, I say to him that the changes to health delivery in Scotland across the various levels should be clinically driven and driven by the various levels of treatment that are required and not by costs. That is a huge issue, as we are designing an NHS service for the next decade and more.
I completely agree with what Adam Ingram said about the poor performance of health boards, and I will knock Borders NHS Board again in that context. Adam Ingram picked up on the location of accident and emergency services. We agree with David Davidson that time is the issue. I refer to the golden hour. A person who is travelling to Ayr hospital for accident and emergency treatment may have to travel a long way. If the accident and emergency department is moved somewhere else, another half hour could be added to that person's journey. The critical golden hour in which lives can be saved represents the test for accident and emergency services.
I think that all members want as many accident and emergency departments as possible so that people are given a feeling of comfort, but providing such services in rural areas is not possible in the way that it is in urban areas. In that context, the training of paramedic staff—who are the first people to reach patients—is all the more important and must be considered alongside the siting of accident and emergency units.
I have no difficulty with first responders, but the issue is having the appropriate level of treatment at the local level. It is not an either/or situation.
I want to compare the Tayside model with what has happened in the Borders. As Euan Robson and I know, 700 people marched in Jedburgh and 700 people marched in Coldstream, not necessarily to save a building but to save an appropriate service, particularly for elderly people in respite care or convalescing or people with chronic conditions such as asthma—I see that Euan Robson agrees with me. Those communities have made a proposal to have combined services, which will be on the minister's desk. In fact, GPs in Jedburgh had a model built up years ago in which there were social services and housing all within the GP complex and a cottage hospital.
In England, 100 cottage hospitals have been reprieved because people see the value of the level of treatment that they involve at the local level. People can travel to such hospitals, which can be right beside their houses. In areas such as the Borders, people, including elderly people, will have to get buses that do not yet exist—travel issues have not been resolved—or drive in their cars to visit elderly relatives. No wonder people feel how they do. It would be common sense to retain such hospitals. England—God bless it—has led the way in keeping cottage hospitals open, keeping people out of general hospitals and keeping beds free so that people are treated at the appropriate level. I hope that when the proposal in question lands on the minister's desk, he will reject Borders NHS Board's proposals on closing cottage hospitals.
There are many challenges ahead in responding to the Kerr report and in delivering on the change in focus of the NHS in Scotland, which we laid out in "Delivering for Health" last October. I welcome the proposition from Margo MacDonald and John Swinburne that the debate should not focus on the negative but emphasise the positive, and I want to respond in that spirit.
Of course, the challenge is not only for ministers or the NHS—it is for all of us. As Mary Mulligan said, if we are to deliver the type of health care that Kerr envisaged, we must move away from the overwhelming emphasis on acute care delivered in hospitals to in-patients that characterised the NHS's first 50 years, and towards a wider emphasis on delivering care to people through improving health across the board.
Margo MacDonald asked about our willingness to work with voluntary sector organisations that represent people with long-term conditions. We very much support such work. For example, we are working with Asthma UK Scotland on plans and clinical standards for children with asthma; we are working with Epilepsy Scotland on the development of managed clinical networks—we have recently provided funding to it; we are working with Voices of Experience, or VOX, to give voice to users of mental health services; and we are working closely with Diabetes UK to refresh the Scottish diabetes framework. We regard the voluntary sector, which represents and talks to and for users of the services, as a key partner in a number of ways.
Several members have mentioned the secondary care sector. The Kerr principles lay out a national framework for service change. That framework does not provide excuses for easy decision making; rather, it sets criteria against which changes must be designed and justified. That is a process that all parties should welcome. The real laziness is in saying that, in spite of those principles, change should always be opposed. We cannot accept the principle of specialisation where it is needed and yet find no case for ever changing anything in real terms.
At what point in the debate did anybody say that?
At what point in the debate did I suggest that that had been said? Let me be clear. There are principles according to which service changes must be justified, and I reject the proposition that no changes should ever happen. Services should be delivered as locally as possible, but they should be as specialised as is necessary. That is why, since the debate last October, we have carried out further work to establish which services need to be concentrated in fewer centres. I emphasise the fact that the default position is the local provision of services.
Several members have referred to the need for proper consultation. The Scottish health council was established last year to act on behalf of ministers in ensuring that the proper processes for public consultation are followed. That is the assurance that we have. The members who referred to those processes will be aware of that and will know that the Scottish health council's views are considered by local health boards when they are making their recommendations as well as by ministers once those recommendations have been brought forward.
The emphasis under the Kerr report will be on keeping people healthy for as long as possible. Improving the health of Scotland in the longer term requires effective action, such as the ban on smoking in public places and our proposals on the promotion of better nutrition in schools. It also requires us to address the issues to do with inequality that were raised by Duncan McNeil. The prevention 2010 pilot projects will have a key role in developing new models of anticipatory care to increase the rate of health improvement in our most deprived communities through the provision of enhanced primary care services and through picking up early what otherwise might turn into serious long-term conditions.
When people develop a long-term condition, we want to slow its progress as much as we can, to reduce complications and to help people to cope with that condition. As I said at the outset, we also want to work with users and carers, who know more than anybody about the nature of those conditions and what it is like to live with them. That is a key task for the Long-Term Conditions Alliance Scotland, whose launch Andy Kerr supported a couple of days ago. When the disease process cannot be halted, people should have the best possible care as locally as possible. Our review of community nursing and the development of the rehabilitation framework underpin that aim.
Our work on neurosciences has shown that even specialised services must have a strong base in the community. That is why we need to see our neurosurgical units as part of a neurosciences service for the whole of Scotland, which involves developing a local tier that is designed to give people the ready access that they want to neurological opinion.
The services that people get must be personal and should be integrated so that all health care and other care that people receive work together. The community health partnerships are the key agencies in delivering that, and schemes of establishment for those have now been approved in most areas. Through the CHP development group, we will continue to support those developments. Likewise, the funding that we are providing for primary care premises is designed to encourage the co-location of services wherever that is possible.
On the subject of the CHP development group, is any work being done to establish where services should be combined into one organisation with one budget, rather than having an agreement to share money?
The joint future programme that is going forward as we speak is very much about encouraging the alignment of budgets and the sharing of premises. Indeed, in some local areas it has involved joint appointments of staff by health and local authority services. That provides us with the right direction forward in those areas.
We have developed a long-term conditions toolkit for CHPs to use in working with people who have long-term conditions. We also recognise the need to support those people in our communities who have complex needs. That involves developing services that focus on the patient and ensure that all the relevant professionals are able to provide the necessary service.
We are taking forward the delivering for health programme and we are delivering on a whole range of issues, including many issues that have been raised today on which there is no time to respond. That approach is central to the development of public services in Scotland. We want to focus on people as people rather than as patients or carers, and we want to provide services that are personal and address all those people's needs. As I said at the outset, the emphasis must be on the positive aspects, recognising that the more successful we are in maintaining people's lives, the more people will live with long-term conditions. We need to work across the board to ensure that people can enjoy the best quality of life in those circumstances.
I thank the minister for what he has said. It is obvious that we are all singing from the same hymn sheet. We all want to put people first and we should be grateful that Professor David Kerr was asked to produce his report, as he stopped the juggernaut that was, for years, the only plan to solve every problem in the Scottish health service—the centralisation of services in Inverness, Aberdeen, Dundee, Edinburgh and Glasgow. That would not suit our geography or our population. John Swinney emphasised the different requirements in different parts of his constituency and the importance of establishing a balance between the need for centres of excellence and the need for local access.
As a former general practitioner—members will know that that is my professional background—I know for certain that 90 per cent of health care work is done in general practice. That is where most general practitioners, nurses and allied health professionals want it to be done. However, buildings can create difficulties in certain areas. I worked in a health centre that was built in 1982 but which by 1990 was not fit for purpose. Medicine moves on and there must always be changes.
Another point to emphasise is that people do not understand exactly what general practitioners and primary care professionals do. Many of the things that people think are new in general practice have already been done. We have been running clinics for chronic conditions such as asthma and cardiovascular disease. If we want to put more into general practice, we must take on board what Nanette Milne said about workforce planning. It is essential that we have a bigger workforce. I know that there is a huge wage bill, but we need specialist nurses for diabetes, lupus and psoriasis and to provide allied arthritic care. I would like to hear that more specialist nurses are being trained who will enter the workforce further down the line. There seem to be a lot of qualified people out there who could be doing a more wonderful job for the patient.
The most precious thing that a health care professional can give a patient is time. In order to think and make the right diagnosis, everybody needs time. Patients love that and will be prepared to wait weeks to see the same doctor. Providing many different professionals does not always solve the problem for the patient. We should listen to the patient.
John Swinburne mentioned deprivation. It is accepted that there are more hospital emergencies in areas of deprivation. If GPs do not have time to think about how they wish to place their patients, there will be more hospital emergencies.
It has always been the case that 80 to 85 per cent of the work of a large major hospital is done in the out-patient department. We welcome all the ambulatory care and diagnostic units that there are around, especially in our city, but in effect they will be doing everything that can be done in a day unit and I think that that will involve split-site working, despite the intention of the European working time directive to put all the doctors into one hospital—or three. There will be hospital units in which out-patient work will be done and there will be split-site working. The doctors will therefore have to consider rotating as they did in Glasgow to keep the casualty department open.
There is a general misconception that A and E departments deal only with accident and emergency cases; people do not think about trauma. A lot of the changes that have taken place have been due to the desire to have combined accident and emergency departments and trauma units. That is why the number of trauma units has been reduced in Glasgow and elsewhere. We know that we can get people to trauma units by helicopter, but it is much better to stabilise people near to where their accident happened and then transfer them. Some cases will require a helicopter, but they are very expensive and the skies will be buzzing with them if everyone has to get to the trauma unit as fast as possible.
The Government is doing a lot of good work on prevention through its work on healthy eating in schools and encouraging children to play in the playground—that exhibition about children and play in the garden lobby was wonderful. As Eleanor Scott said, it is astonishing that there are 80 acres of golf course to 1 acre of playground. The swimming pools that used to be all around our cities were all closed because they were all neglected. The Victorians were pretty great at knowing what we needed, even though we had other problems, all those years ago. Many swimming pools were closed and we have had to build news ones, but we do not have enough. Aquatherapy is important.
We need more physiotherapists and allied health professionals. When we are making any changes, we should consider that change should not be for its own sake; it should provide at least the same service or a better one. I would like us all to consider that.
We sit in front of a mace on which are written the words "wisdom, justice, compassion, integrity". When he accepted the mace from the Queen, Donald Dewar said:
"Timeless values. Honourable aspirations for this new forum of democracy, born on the cusp of a new century.
We are fallible. We will make mistakes. But we will never lose sight of what brought us here: the striving to do right by the people of Scotland; to respect their priorities; to better their lot; and to contribute to the commonweal."
We all have that in our hearts and I think that the Scottish Executive has it in its heart. However, it needs to listen to more front-line managers, perhaps get rid of some targets, do more monitoring, and think and plan ahead.