Plenary, 18 Sep 2003

Meeting date: Thursday, September 18, 2003

Official Report 658KB pdf

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Improving Scotland's Health

Resumed debate.

On a point of order, Presiding Officer. With reference to this morning's debate and its continuation this afternoon, will the Presiding Officers reflect on previous rulings stating that members who wish to speak in a debate should be present at the start of that debate, particularly given that some of the members who were called in the morning were not present for the minister's opening speech, or for the Opposition parties' speeches? Will the Presiding Officers consider that when selecting speakers for the continued debate?

There is a basic courtesy to be observed in attending the chamber for opening speeches, and I am sure that we all agree with that. If members want to contribute later in the debate, they should certainly be in the chamber for the opening speeches. It is, however, up to the Presiding Officer to call members in a debate. Non-attendance at the start or summing up of a debate is taken into account when we call speakers in the future, and I have noted Mr Barrie's comments. We shall now continue the debate.

I was delighted to be here this morning and have the opportunity for such a wide-ranging debate, without the necessity of looking for points of difference with members of the Opposition. I was pleased to hear members from all parties speak positively in favour of broadening the range of activities that we need to improve lifestyles.

Janis Hughes raised the issue of carers. A couple of days ago the Fife carers centre newsletter was sent to me. Among other things, it refers to the service for young carers in Fife, and says that dedicated staff have been appointed to that service thanks to the changing children's services fund provided by the Executive. I would be pleased to arrange for further information to be sent to the minister if he wishes.

Many members have referred to evidence from overseas, particularly from Finland. I received a briefing from the chair of my local health care co-operative in Glenrothes that says that in North Karelia

"it was the concern of the women of that area about their poor health records (and that of their male relatives) that provided the stimulus to improve the health of that region."

As some of the Opposition speakers said this morning, in Scotland we still have a dependency culture that holds us back to some extent. The Executive's encouragement of community development and community-based solutions will go a long way to improving people's confidence in their ability to take care of their own health.

I have another piece of information from the same briefing that I am sure will be of interest to all my male colleagues. I will pass on the web link. The site shows that men aged over 50 who exercise regularly are less likely to be impotent. [Interruption.] I knew members would find that interesting.

There is also significant evidence that the secondary prevention measure that is most effective in reducing total mortality after coronary heart disease is smoking cessation; there is a 36 per cent reduction in total mortality. I concur with all the members who have talked about the importance of stopping smoking in building a healthier lifestyle—and I congratulate Jamie Stone, who is on his sixth day without cigarettes and is not using patches.

I shall focus my remarks on the two generations at either end of the health improvement spectrum: the elderly and young people. One of the best things that the Parliament did during its first session was set up the joint future initiative, which obliged health boards and local authorities to propose joint plans for community care for the elderly.

Those had to be costed, and additional money was applied to those costed plans. As time has gone on, there have been increasing concerns about resource transfer. The benefit of that first tranche of money was a reduction in in-patient bed days for the elderly, and there are concerns that there is insufficient resource transfer from the acute sector to the primary and social care sectors. For example, there are concerns about the funding of aids and adaptations, and the speed with which they are provided. I ask ministers to hear that point, and to make inquiries about what steps can be taken to address the problem.

I have to declare an interest—I declare that I am, over 50, but I will stop there.

Can Christine May tell us about the experience with joint future in her part of the country, because there is great confusion among councils in the north-east of Scotland about the variations in how the initiative is working out? Even some documents within the same health board appear different. Has the member had the same experience? Does she think that Executive input is required?

I cannot comment on other areas, but my own experience has been good.

Finally, I turn to the health of young people. I am grateful to the members and colleagues who signed my motion welcoming the establishment of the Place in Glenrothes. That is a young persons' health and welfare centre, funded jointly by the local authority and the local health care co-operative—sometimes in spite of the regulations and accountability lines, which are more like chain mail and steel bars in their inflexibility. I ask ministers to ensure that civil service and other bureaucratic regulation does not get in the way of the collaborative approach that we all want.

A significant number of members wish to speak, so I propose that we move to five-minute speeches. Even so, I will not be able to call everyone.

I shall take the opportunity afforded by this debate to highlight the plight of people who are suffering mental illness, and that of their carers and all those who work on a daily basis to provide care, treatment and rehabilitation services. We cannot divorce the health improvement agenda from the state of our national health service, especially with mental health. I know that this has been said many times in the chamber, but it bears repeating: the mental health services remain the Cinderella of the NHS. That is undoubtedly a function of the stigma attached to mental illness, which still pervades our society.

Politically, not nearly as much kudos is to be gained from devoting resources to mental health as from devoting them to, say, cancer or coronary care. However, like cancer and heart disease, mental health is a national clinical priority—as it should be, given the statistics. Suicide is the leading cause of death for Scots males aged 15 to 35, and the rate is twice that in England. Around 12,000 people develop dementia every year in Scotland. Up to 35 per cent of absences from work are caused by mental health problems. However, no outcome targets have been set for mental health. Why is that? Unless targets are set, how can we measure performance or gauge any improvements?

Money tends to leak from mental health budgets, particularly at area board level, which reflects the low political priority given to mental health, in contrast to the lip service paid to it. I am sure that ministers are aware of that problem, but if they are really serious about tackling it, and if we are to deliver on the framework for mental health, I see little alternative to ring fencing.

In the last session of Parliament, many of us were involved in passing the Mental Health (Care and Treatment) (Scotland) Act 2003. That is an enlightened piece of legislation that we hope will lead to a better deal for people with severe and enduring mental illness, who need help most. The new test of our commitment will be whether we can implement the act so as to ensure that the resources and services required to make it work are in place. Clearly, that will be a tall order.

Does the member agree that one difficulty is that too much money is tied up in acute mental health services, and not enough recognition is given to community mental health services, which can prevent people from needing acute beds? The right balance between acute services and community preventive mental health services would go a long way towards solving some of the difficulties to which he has referred.

I agree with Scott Barrie, and I shall be interested, as I am sure he will, in Dr Sandra Grant's final report, which will be produced later this year.

Committees have expressed concern about resourcing to implement the 2003 act, and those fears were underlined at last week's meeting of the cross-party group on mental health by Dr Grant, who is conducting a review. She highlighted a serious shortage of professionals across the discipline, from consultant psychiatrists—we are 40 short of those—to mental health officers. Even more worrying is the extremely low morale and low level of energy. For example, she said that GPs have a marked aversion to taking on more mental health work. I was struck most forcefully by her comment that people who deliver the service feel paralysed by the scale of the task that faces them, the lack of resources and the struggle to establish effective joint working.

The work force recruitment and retention problems that have been reported throughout the NHS are writ large in mental health services. That is the challenge to which the Executive must rise, and on which it must be held to account by the Parliament. Advocates of the devolution settlement need to be judged on such issues.

No one would disagree that establishing healthy living for our children today will mean that they enjoy the benefits throughout life. I am therefore grateful to have the opportunity to contribute to today's debate from the Education Department's point of view. The health and well-being of children and young people obviously affect their ability to learn with confidence and to achieve their full potential, so it is essential to secure healthy living in a child's earliest years, and right through their time at school.

Sure start Scotland is a key element in the Executive's drive to ensure that every child has the best start in life. Sure start involves local authorities and their partners developing local services to meet the needs of local families with very young children. Those include integrated services in community nurseries and family centres, mobile and outreach services, mobile crèches, mini family centres and healthy living programmes delivered by health visitors.

All those services contribute to our aim that by 2006, at least 15,000 vulnerable children under five will have an integrated package of health care and education support. The sum of £23 million has been allocated to local authorities for sure start programmes for the present financial year, and that will rise to £35 million in 2004-05 and to £50 million in 2005-06.

In addition, the Executive has a range of early-years policies that have an impact on children's health and well-being. We need to meet children's needs in a co-ordinated way and we are consulting on an integrated strategy for the early years. We hope to issue a finalised strategy by early 2004.

In schools, the aim in health education is to help pupils to enjoy good physical, emotional and social health. The aim is to nourish values and attitudes that will develop self-esteem, concern for others and care for the wider environment.

The health-promoting schools programme is designed to ensure not only that health education is integral to the curriculum, but that a school's ethos, policies, services and extra-curricular activities foster mental, physical and social well-being and development.

We have set schools a challenge. By 2007, we expect all schools to achieve health-promoting school status. In the partnership agreement, we say that the advertising of unhealthy foods in schools should end, and that the availability of unhealthy food and drinks in schools will be actively discouraged as a condition of their becoming health-promoting schools.

However, we do not expect schools to do that alone. We have set up the Scottish health-promoting schools unit, which, in partnership, will play a key leadership role and will champion, facilitate and support the implementation of health-promoting schools throughout Scotland. It will also help schools to make sense of, and integrate, every vital health theme, including those concerning alcohol, smoking, drugs, sexual health and relationships, good nutrition and physical activity, to name just a few.

I am heartened to hear there is a multifaceted approach involving different Executive departments and the public sector. However, the minister began his speech by referring to parents and then went on to talk about needy children. He has not mentioned parents since. Parents often have contact with one another and with those who look after their school-age children through the school system, and I wonder whether the Education Department will educate parents to the standard to which it wants to educate their children.

The member has made an important point about parents' involvement. I do not think that the department would educate parents per se, but it would certainly do so through involving them in the process and spreading good practice in that way. Perhaps we can return to that issue later.

We can all take certain important actions. For example, we know that, as a nation, we all need to change our diets and increase our physical activity. I recently found out that 27 per cent of boys and 40 per cent of girls aged between two and 15 do less than one hour a day of moderate activity on five or more days a week. Activity drops sharply in the early teenage years, and that decline continues into later life. We need to reverse that trend and encourage our young people to adopt healthy practices from the outset, to sustain them in adulthood.

This morning, Malcolm Chisholm mentioned that £24 million has been committed to expanding the active primary school programme. Furthermore, another aim of "Sport 21", the national strategy document for sport in Scotland, is to have a school sports development officer in every secondary school. By July 2002, 340 secondary schools had such sports co-ordinators.

Improving children's diet can have a major impact on their health now and in later life, which is why we are investing in our school meal service. Presiding Officer, I see that you are about to tap your microphone, so I will not go into all the details of our policy document entitled "Hungry for Success: A Whole School Approach to School Meals in Scotland". Suffice it to say that over the next three years, £63.5 million will be invested in implementing the vision of a revitalised school meals service in Scotland.

I could have made many other points. However, I am grateful to have had the opportunity to make a few comments from the Education Department's perspective in this debate.

In the interests of clarity, I want to return to the issue that Christine Grahame raised about the form of this debate. As a former member of the Procedures Committee, I recall that I raised concerns about this kind of debate when the matter was discussed. However, the SNP member on the committee did not raise any such concerns at the time. As a result, we should accept that all parties have agreed to the form of today's debate.

I mean no disrespect to the ministerial team, but I have to say that I welcome the publication at long last of a document that is not littered with politically correct photographs and images of the team. Instead, this is a glossy action document that actually sets out the way forward. However, it might be helpful if, in addition to that document, we had another document that looked back at the Executive's previous commitments, tracked whether they have been met and gave a specific focus to the issue.

As some members have pointed out, this wide-ranging debate has touched on both acute and primary services. That brings me to the subject of consultation, and how we improve primary and acute care services. Many of the health boards are obsessed with consultation documents. People in our communities want to know how those documents have been responded to. One of the documents from the Greater Glasgow NHS Board says:

"Tell us what you think about your local services."

That is a welcome phrase, but at the time of the acute services review in Glasgow, did the health board interrogate the views that people presented to them?

In order to improve health, particularly the acute and primary care services, we must put across the message that local views have to be considered. Consultation exercises must not become information exercises, as a number of them have been; instead they should give serious consideration to people's views and result in movement on the issues raised.

Frances Curran talked about health board representation earlier. Her point was well made, and I have made this point several times in the chamber: many of our constituents are good enough to serve on the boards of housing associations, community councils and health councils, but those same people do not have the opportunity to serve on our quango health boards. The sooner we consider Bill Butler's proposed member's bill the better. We must ensure that it is not always the so-called great and good who are considered good enough to serve on our health boards, but genuine local stakeholders who can offer their experience in their communities to ensure that all local views are considered.

We have discussed healthy lifestyles again today, as we often have, and we have raised the issue of how we get the message about healthy lifestyles across—to young people, in particular. When I met the minister yesterday, I made the point that many designer brands—I do not want to advertise them here—are capable of getting their message across to young people. Can we look at ways of emulating those brands' methods, so that we can find more effective ways of ensuring that young people have healthy lifestyles? Margo MacDonald made the point about the need to ensure that sports personalities—and other people to whom young people look up—play a more prominent role in getting the message across to young people.

The minister has always given consideration to Glasgow, and I welcome his comments on additional funding for Glasgow. To finish on a famous quote:

"A government that robs Peter to pay Paul can always depend upon the support of Paul."

That is a serious issue for Glasgow.

We have had a wide-ranging debate today. In addition to making one or two observations about health provision in general, I will make one or two comments on health provision in the kingdom of Fife.

We are told that Scotland is now up there with Europe's biggest spenders on health care. However, Scotland remains the sick man or woman of Europe in many areas. In coronary diseases of women, in a number of cancers and in diseases of obesity, the figures are—far from improving—getting worse. As ever, the statistics are worse in deprived areas.

Far from coming down, waiting lists have gone up by 22,000 in the past four years. The numbers of cancelled operations, hospital-acquired infections and vacancies for medical staff across almost all the NHS board areas have increased in the same period. Conservatives are, of course, inured to the weary chants of our opponents that we plan to abandon the NHS. Nothing could be further from the truth. What matters is where patients are treated and the quality of the treatment, rather than the sector in which that treatment takes place.

I will follow those introductory remarks by considering the provision of health care in Fife, specifically aspects of communication. I believe that Fife NHS Board discharges its responsibilities better than many boards. I am in regular contact with the board and hope to meet it again tomorrow. However, the lack of hard information that constituents in all parts of Fife get from the board and the conflicting nature of the information that is received are among the most frequently expressed criticisms from constituents.

Like other health boards, Fife NHS Board has to cut its cloth and a number of options were examined as part of the cost-cutting exercise. This summer, there were threats to the accident and emergency department in Kirkcaldy and lurid headlines appeared in the local press. The closures did not happen, but little reassuring public explanation was given. This week, we have learned that, three months after proposed cuts in accident and emergency services were shelved amid considerable public alarm, they are back on the table.

Earlier this year, operations had to be cancelled at Forth Park hospital and at Queen Margaret hospital in Fife, as there were no surgical instruments with which surgeons could operate. The board had decided to have the instruments sterilised at Ninewells hospital in Dundee, but they were not returned sufficiently quickly for vital operations to be carried out. Sterilisation at Ninewells hospital was supposed to save Fife NHS Board £200,000 a year, but again there has been little information from the board about whether savings were made or whether there was a better service.

The board admits that the Adamson hospital in Cupar desperately requires renovation and modernisation. Three months ago, the board claimed that it was considering future development in detail. Many people in Cupar are concerned about the hospital's future—or perhaps the lack of a future—and fear that the hospital will close because of the development of the hospital at nearby St Andrews. Despite assurances from the board that that is not the case, there is still no official word about when the hospital might be upgraded.

The future of Stratheden mental hospital has been in doubt for nearly two decades. The board has said that retaining Stratheden as well as Fife's other two mental hospitals is not sustainable, but we are still waiting for a decision on whether Stratheden—which is widely recognised as a centre of excellence—will be retained.

Finally, there is the vexed and lengthy saga—it has been running for more than a decade—of the proposed new hospital for St Andrews. I understand that, last week, the Executive approved Fife NHS Board's outline business case for the proposal to build a new hospital at Largo Road in St Andrews and that the hospital is to be ready in three years. Despite the assurances that were given to everyone at Fife NHS Board's board meeting that communications were being improved, the board for some reason omitted to inform me of the Executive's decision and I had to read about it in the local paper, despite the fact that I am one of the area's MSPs and happen to live in St Andrews.

I am not criticising the board's ever-helpful information staff, with whom I have excellent relations, and I sympathise with the argument that at a time of cost cutting the board cannot be seen to be beefing up its spin. However, the public and their elected representatives deserve to be taken into the board's confidence at the earliest opportunity in order to allay fears and quell rumours. Fife NHS Board and other health boards in Scotland should take note.

Scotland's health should have its heart in the country's remote areas. Many things can be learned from practices in remote areas to help people in the conurbations.

Scotland's poor public health record makes for a sad comparison with the records of small northern European nations such as Finland, Norway and Sweden. We must explore why that is the case and ask what measures we need to take to create greater self-esteem. We must recognise that preventive public health measures take a long time to work and, therefore, that sustained investment will be required to bridge the gap between Scotland's life chances and the life expectancy figures of neighbouring nations.

The Highlands and Islands have a specific health profile, as the Scottish Executive has recognised. A four-year project was set up in 1999 to consider the remote and rural areas as an entity—the remote and rural areas resource initiative has begun to develop health care services and support for professional staff from Galloway to Shetland.

The demographic shift of young people out of the area and older and retired people into the area masks the stark health picture of the lowest income quartile of its residents. In the Highlands and Islands, the life expectancy of men is below the Scottish average, which in turn is a year and a half below that of Finland, three years below that of Norway and five years below that of Sweden. Mortality and distance are key factors in health provision, so RARARI's backing of, for example, the aortic aneurysm screening programme for men in the 65-to-74 age group is a key example of raising life expectancy by early intervention. Moreover, the mobile wheelchair repair service is a great boon for its 3,000 or so users in the Highlands and Islands. Members can imagine how difficult it is to service so many people in so many remote areas.

To make progress with those and other issues, RARARI must be transformed into a permanent faculty of rural and remote medicine, perhaps co-hosted by the UHI Millennium Institute and the University of Aberdeen's Highlands and Islands health research institute, which is based in Inverness. The minister's response on that issue is crucial.

Cross-departmental issues have a big bearing on good health and I will mention two. The North West Cattle Producers Association aims to grow more native beef and to sell it to local markets before thinking about exports. However, unless the Scottish Executive's forward strategy for agriculture does everything that it can to encourage such schemes, more families will opt out of living in the area and fewer people will be able to afford the prime beef that is on offer, given the chronically low wages.

The well-being induced by playing music is an international phenomenon. The Gaelic-music fèis movement regularly involves more than 4,000 young Scots every year in focused musical activity. The Fèis Rois outreach programme takes young traditional musicians into primary schools in social inclusion partnership areas. I would like members to hear the response of a teacher from East Ayrshire on the health implications of a recent visit by a group of musicians. The teacher said:

"The morning the team arrived had been particularly difficult due to external factors. The group lifted our spirits and helped focus our minds. Our children with special needs in particular dyslexia benefited considerably from the experience. Two days later a group of P3 children created their own dance and demonstrated it to us in the playground."

The teacher went on to comment that to develop the ideas would take a good deal more specialist training and funds.

We are developing well-being and public health interventions that stand comparison internationally, but we have much to learn from the Finns and Swedes. In the far north of Norway, there is an excellent programme to retain and recruit young doctors. Through group working, that programme achieves far greater levels of recruitment and retention than those in the north of Scotland, where the conditions are much easier. We should use such international comparisons to try to improve our game.

I will end by quoting one of the speakers at a major conference on international medicine, Dr Jane Farmer from Aberdeen, who said:

"The well-being of rural areas is an issue for all Scottish people and decisions about health service redesign must be taken within a holistic planning context"—

which means not just by the NHS—

"and informed by evidence about impacts on wider rural community sustainability."

Our Parliament must not fail remote and rural areas, because a third of Scots live in them. Our health service should be an international example, not an afterthought.

I beg your leave to go, Presiding Officer, because I have an urgent constituency matter to deal with.

I recognise that members have mixed views about the nature of the debate, but I think that the new format is good, because it has allowed back benchers from all parties to express views and to produce ideas without being constrained by the need to support or defend amendments and motions.

In that spirit, I will mention a few of today's speeches. Janis Hughes's comments about the role of carers in improving health were thought provoking; I hope that we will be able to develop some of her ideas. Margaret Ewing spoke about staff commitment and the positive results of the service. All members were moved by her resonant comments about Alzheimer's disease and dementia. I hope that some of her ideas, too, will be considered further. Paul Martin has long advocated democracy in health boards and he referred to Bill Butler's proposed bill, which I, too, support. We have been able to bring ideas to the chamber today and I think that that has been a very good thing indeed.

I want to mention a few projects in my constituency. I am especially proud of the one that relates to one of the new community schools and is based on the national water is cool in school campaign. It encourages children to drink water, teaching them that water is good for concentration, and it assists in the promotion of sensible dental health regimes. As with anything, if children are introduced to something early on, they will develop a taste for it.

In identifying priorities, the new community cluster schools in my constituency purchase water bottles for their associated primary schools. The project was accompanied by an information leaflet, which had been drawn up by oral health and health improvement experts and which identified the importance of encouraging children to drink water. As with most health improvement projects, we will not necessarily see or feel the benefits of that one this week or next week, but I believe that it has been an investment for the future. It has not been undertaken within the context of a politically expedient timetable, but it was identified in the local area by the local community and the benefits will be seen in the generations to come.

To illustrate the importance of promoting positive mental health in local communities, I draw to members' attention another project in my constituency: the North Ayrshire mind to volunteer project. The project is based in the three towns and Kilwinning and uses a combination of primary care grants and health improvement funding amounting to almost £200,000. Its aim is to enable people with mild to moderate mental health problems to benefit from volunteering assistance, to help them to make necessary changes to their lives. The majority of the volunteers have experienced mental health problems and are therefore uniquely placed to listen and understand. They also gain in self-confidence and benefit from the process of volunteering. Additionally, the project promotes general awareness in the local population of the needs of people with mental health problems and it is to be commended.

Members have spoken about tobacco quite a bit today, but I want to talk about it in the European context. Like pollution, disease is no respecter of borders. It would be impossible to have a debate on health improvement without talking about tobacco control throughout Europe. Tobacco is not only the single biggest cause of avoidable death in Scotland; in the European Union as a whole, 500,000 people die every year as a result of smoking.

You have one minute.

I am running out of time, so I will have to cut to the chase.

I feel that it is absolutely morally wrong that we put so much money into tobacco subsidies in Europe year in, year out. The money amounts to about €1 million a year, but only about 5 per cent of it goes back into health promotion in Europe. I hope that that problem will be highlighted.

On a more positive note, I mention briefly the European Commission's feel free to say no campaign, which targets young people in the 12-to-18 age group. Incorporated into that is something that Margo MacDonald and Paul Martin mentioned: music stars saying no to tobacco. The idea is to give children style icons to whom they can look up who will promote a positive, no-smoking message.

I am out of time, so I will close.

I identify totally with Irene Oldfather's comments on tobacco in the European context.

That is a first.

It is a first, but it is a sincere agreement.

Malcolm Chisholm rightly emphasised the need for interaction—not just within the NHS, but among other departments and groupings—to achieve the aims that are set out in the document. I go along with that. However, I point out that those interactions are sometimes dependent on actions that the Government takes in other areas, as I will demonstrate shortly.

I commend the First Minister for being prepared, as he demonstrated in his response to John Swinney today, to consider ideas about the involvement of the private sector in trying to deliver a better health service. Conservative members agree with that. We are talking not about privatisation, but about using the country's resources to the best advantage.

I make no apologies for reiterating one or two of the Ayrshire issues that John Scott mentioned earlier in the debate. For more than 20 years, I have, on and off, been involved in health issues as an elected representative for Ayrshire. I have always felt that health was an important issue. However, our health services will not be improved just because of a new document or as a result of the aims that have been stated today in the chamber.

Some of the best advances in health care in Ayrshire came about in the mid-1990s, partly as a result of redistribution of funding to the Ayrshire and Arran Health Board, as it was called at the time. I pay tribute to some of the people who were involved in, and should take great credit for, that work: Bill Fyfe, the chairman of the board; Douglas Brown, chairman of the South Ayrshire Hospitals NHS Trust; Donald McNeil; Aileen Bates; and Jim Eckford, the chief executive of the board. All of them played a significant role at that time.

Today, we are still talking about improving hospital services. The leaflet that I am holding up is called "Improving Hospital Services for Ayrshire & Arran's Children" and was produced by NHS Ayrshire and Arran. Although I go along totally with the sentiments that are expressed in the leaflet, when I read it I found that the service is to be improved by shutting the children's ward at either Crosshouse or Ayr hospital. In other circumstances, perhaps, such a closure might be seen to be the way ahead. However, it does not seem to me to make sense to issue a leaflet that talks about providing better services only to relate that aim to the fact that a children's ward is to be closed. The threat of closure creates a degree of mistrust between people and NHS Ayrshire and Arran.

One of the reasons why the closure is felt to be necessary is the shortage of consultants and the lack of junior doctors coming through the system. I referred earlier to Malcolm Chisholm's comment about interaction. I ask him why not enough doctors are coming through. Are a sufficient number of students going through the universities? Is there a fallback position to six-year courses? We also have to question the Executive's position on tuition fees and the removal of grants. Do those issues play a part in the problem? I am not making a political point; I am laying down the facts that we have to take into account when we consider these issues.

We have similar problems in accident and emergency units, so I congratulate NHS Ayrshire and Arran on going out and finding the extra consultants that it needs. On Tuesday night, I had reason to use the accident and emergency services at Ayr hospital. From the time that I picked up the telephone to phone through to the Ayrshire doctors-on-call service, to the time that I left the accident and emergency services some three or four hours later, I found that everyone involved was tremendous. I was extremely satisfied with the service that I am paying for.

Many other issues are involved. The Government's "The same as you?" document poses another threat for services in Ayrshire, in that it has led to the proposed closure of the Arrol Park facility. Adam Ingram's comments on Arrol Park were well worth listening to; he made a tremendous case for the facility. A mandatory statement has been made for the facility to close within the next five or six years. That is not the way to improve services in Ayrshire for people who are mentally impaired. The proposed closure is a great mistake.

it is time to close, Mr Gallie.

Mike Rumbles referred to the requirement for an additional 12,000 midwives and nurses by 2007. I say to the minister that, if he is to achieve that number, the students had better start their courses today. That is the time scale in which to train those midwives and nurses for 2007.

I am possibly in a minority today, as I have not found the debate particularly useful. Shona Robison, who I think was the second speaker this morning, said that the debate was wide ranging and unfocused and could have been entitled, "Health: discuss." Having sat through the debate today, I suggest that the debate could just as easily have been called, "Predictability: discuss."

The debate has been quite interesting. However, we would hope that, when we have a whole day in which to discuss health without a motion to vote on and when members are not meant to be partisan, the debate would be illuminating and some good ideas would come out of it. We have heard examples of good practice in various parts of Scotland and we have heard about problems in respect of health in Scotland, but those have been discussed before. I do not think that we have heard anything new.

Members have also been a bit partisan. The nationalists tailed off into arguing that the solution to Scotland's health problems is a constitutional one. David Davidson pointed to back-door privatisation of the NHS as the solution to our health problems. However, it was interesting to hear him state that the Conservative party wants

"a health service that responds to the needs of … the patient"

and that we should move away from the

"top-down approach".

He said that as if it had always been the Conservative position on the NHS. That demonstrates that a Scottish Tory in the new user-friendly Tory party can, on occasion, opt for delusion over despair.

My comments perhaps represent an over-simplification of members' positions, but they are pertinent to the point that I want to make. One of the major contributors to the health debate and to forming health policy is the media, which I do not think have been mentioned today—I am one of the members who have sat through the whole debate.

I was interested to hear an item on "Good Morning Scotland" when I was driving through to Edinburgh at some ungodly hour this week—I think it was on Tuesday—about the King's Fund report, "Health in the News". I have read only the summary, although I look forward to reading the full report. The report's analysis of the relationship between politicians, the media and the public seems to go to the crux of our problem with improving public health and the health service in Scotland. Roger Harrabin, who conducted the survey, found that the imbalance in the media coverage of health-related issues means that far more prominence is given to scare stories and to NHS-in-crisis stories than to issues that have justifiably been discussed here today, such as the effects of smoking, alcohol and poverty on health. Most members have mentioned at least one of those issues today.

Even more worrying is the fact that some media coverage is so persuasive that it has an impact on people's behaviour. The most obvious recent example concerns parents who have chosen not to have their children vaccinated with the combined measles, mumps and rubella vaccine. The media coverage about that stemmed from one scientific report that linked MMR with autism. No weight was given to the numerous scientific reports that refuted that link. The coverage by the media—in collusion with politicians; I am not blaming only the media—has led to a significant decrease in the uptake of that vaccine. That could lead to serious health problems for young people in the future.

Another matter that members should all be aware of, but about which we all seem incapable of doing anything, is the effect of the media on us as politicians. We are all guilty of overreacting to media coverage of local health issues. At a local level, the closure of buildings, the opening of new buildings and acute services reviews have us all metaphorically flinging ourselves down in front of the bulldozers.

I have a minute left, so I will have to cut short what I was going to say. There are many examples of cases in which, although the media might not necessarily represent public opinion, they give us the impression that they do and we shape health policy based on that. That gets in the way of our having a dialogue about real issues that affect health in Scotland.

If the media were to use their significant influence to publicise issues that affect health, such as those that have been discussed in the debate, and if politicians tried not to be parochial but to take a wider look at health matters, we could have a serious dialogue that would lead to improvements in health and health care and to radical changes in the way in which we deliver health services. Until the media and politicians can do that, we will not reach that stage—I certainly do not think that we have reached that stage today.

I was one of the members of the Procedures Committee who was enthusiastic about trying out debates without motions. It is excellent that we are doing that. I feel that Kate Maclean destroyed her own argument. She spent part of her speech saying that conducting a debate without a motion was a waste of time, and the rest of it making useful and constructive remarks, which she would never have had the chance to do in the usual yah-boo debate that we have to suffer so often. For example, one side says, "Aren't we running the health service marvellously?" and the other side says, "No, you're a load of rubbish."

I think that many constructive remarks have come from the debate, but I will focus on only a few, because many have been well covered already. First, the debate is a debate on health; it is not a debate on sickness. There is an issue to do with the well-being of the Scots in the widest sense. There is the question of self-esteem, which does not mean that someone has to go about feeling smug. If someone is reasonably content with themselves, their life and how they go about matters, they will be much less likely to fall ill than they would be if they were depressed and lonely. Not only is encouraging feelings of self-esteem and self-worth throughout our community important in a positive sense, it could save us a lot of money in health provision.

I do not know the answer to the problem of getting proper democratic control and accountability into the health service. One view is that we should elect health boards—or whatever they are called at any given moment; they seem to change name with great frequency. I think that there are arguments against that view. However, are appointed health boards properly accountable? We do not want the minister to manage all the affairs of health boards, as they are trying to do that themselves. However, a huge amount of money goes into health boards and there is a feeling that the money disappears into a black hole. We must develop a system of accountability for health boards that measures outputs against the money that is put in.

We must invest more in preventing people from becoming sick in the first place. That approach covers a huge range of aspects. Obvious ones are sport, community activities and the arts. If people had worthwhile things to do, such as, in particular, taking more exercise, they would not fall ill as much as they do. I used to help a discussion group of people in a poor area, who supported one another. Many of them had stopped taking pills. The saving to the health service from that was huge, but the group's funding was extremely precarious. We must find a more useful way of spending the health budget. I know that there is an effort to fund sport and healthy living, but we must do more of that and help community activities that reduce the amount of sickness and keep people healthy.

An issue that members frequently get lobbied on is the recruitment and retention of nurses. There have been efforts to address that issue, but there seem to be difficulties about the flexibility of contracts, which vary considerably from place to place. We need to arrange matters so that people are attracted into nursing or back into nursing, or are persuaded to stay in nursing. A housing association that specialises in helping people raised a specific point with me on the issue of care assistants in houses for people who need help. There is a long queue of people who want to do that job, but there is a dearth of training places. Money directed into training more care assistants would be helpful.

On that line, we could further explore the issue of people who are a bit skilled at what they do but not as expert as the top people. For example, there are many intelligent and able hospital cleaners who could be trained up to do more jobs in the hospital, which would help nurses. People do not have to be only generals or private soldiers. We can promote quite a lot of the privates to be sergeants, who are the people who really run the place anyway.

I welcome the opportunity to debate the improvement of Scotland's health. I intend to concentrate on the provision of services within Forth valley.

For many years, Forth Valley NHS Board has been conducting a review of acute services but, until recently, the board had failed to reach any firm decisions on the matter. The dedicated staff at Falkirk and Stirling royal infirmaries do a great job, but changes in medical practice, inadequate buildings and shortages of skilled staff make it increasingly difficult to justify the continued existence of two general hospitals for the population of Forth valley.

For many years, the health board dithered around and there is a genuine fear that, unless firm decisions are taken now, services could be lost, which would mean that patients from Forth valley would have to travel to Edinburgh or Glasgow for treatment that could and should be provided locally.

Earlier this year, the health board at last reached a unanimous decision in favour of building a new hospital on the site of the Royal Scottish national hospital at Larbert and it submitted an outline business plan for approval by the Scottish Executive. The decision in favour of the Larbert site was taken after the most extensive public consultation that the board had ever conducted.

We now have a situation in which some parochial politicians are trying to overturn the result of the public consultation process.

My colleague will not be amazed about the question that I ask. Does he not agree that there have been two significant recent changes to the situation pertaining in January? First, it appears that a site at Pirnhall in Stirling, which had been identified before, is now more available and could therefore be considered alongside the Larbert site.

Quickly, please.

Secondly, we now have the feedback from the transport study, which shows that transport access to Larbert would be quite horrendous, not only for the people of Stirling, but for people in the rural areas. Would the member not agree?

On the transport issue, the criterion that was laid down during the consultation period was that at least 90 per cent of the population of Forth valley should be able to access the proposed new hospital within half an hour. It is clear that the RSNH site meets that criterion. On Sylvia Jackson's other point, that is not new information at all. The health board considered that information before it reached its unanimous decision.

I can understand Sylvia Jackson's efforts to fight her corner as the MSP for the Stirling constituency, but what I find completely unacceptable—I am choosing my words carefully here—is the deceitful intervention of a UK Government minister, Anne McGuire, on a devolved matter, by issuing statements that are blatant untruths. Speaking about her desire to locate the new hospital at Pirnhall near Stirling, Anne McGuire told the Stirling Observer:

"it was obvious the Pirnhall site was dismissed out of hand and without any analysis".

She went on to refer to the health board's tunnel vision and called on the board to conduct a full study of the Pirnhall site at this late date.

Mrs McGuire failed to mention that the Pirnhall site was given full consideration during the public consultation. The board also commissioned independent consultants and, after it had considered the consultants' report and the views that were expressed during the public consultation, it came to the unanimous conclusion that the RSNH site at Larbert was the only one that met the four agreed criteria.

Even if, as Sylvia Jackson suggested, a developer were to offer land at Pirnhall at no charge to the NHS—that is a big if—such an offer would depend on planning approval being given for a major growth area in Pirnhall. A public inquiry would be inevitable and the whole process could delay the construction of the new hospital by another three years.

On a point of order, Presiding Officer. Is it fair that a member can say something that is totally untrue?

That is a matter of dispute, not a point of order.

I have said nothing that is untrue. On the contrary, Anne McGuire's statements to the Stirling Observer are blatantly untrue.

The people of Forth valley have waited far too long already for a new hospital. Any further delay could jeopardise the very existence of local services. We have the opportunity of a lifetime for a new state-of-the-art hospital, built on NHS land at a central location in Larbert, that will serve all the people of Forth valley, whether they live in the Falkirk area, the Stirling area or Clackmannanshire. That opportunity must not be missed. I urge the minister to expedite approval so that the new hospital can become a reality at the earliest opportunity.

I apologise for not being present at the start of the debate this morning. Unfortunately, I was detained on constituency business. I know that some members have been concerned about that matter, so I want to make it clear that I would obviously have preferred to have been here but for that rather unfortunate coincidence.

I start by focusing on cancer, which is widely acknowledged as Scotland's biggest killer. I welcome the Executive's proposed target of reducing cancer-related deaths among people under the age of 75 by 20 per cent by 2010. However, if we want to reduce cancer, the first thing that we should do is join the ever-growing list of countries that have introduced anti-smoking legislation. In 1988, California introduced such legislation and subsequently found that cancer incidence rates declined by 10 per cent in the following decade. More important, cancer mortality rates declined by an impressive 14 per cent over the same period.

Surely those figures show that one of the most important steps that Scotland could take to rise to the challenge of improving Scotland's health would be to introduce similar anti-smoking legislation here—the sooner, the better. Legislating on smoking would send out a clear and unambiguous message to the Scottish people about how seriously we approach the issue of smoking and the ill health and death that it brings to many of our fellow Scots.

We all know about the more obvious problems that are associated with smoking, but smoking during pregnancy is one of the leading factors in incidences of low birth weight. Other reasons for low birth weight include poor nutrition, excessive drinking while pregnant and, obviously, socioeconomic deprivation. However, when health is being discussed, the issue of low birth weight is often overlooked—both the cause of it and the consequences that flow from it.

Low birth weight is strongly socially patterned. In Scotland, the number of full-term babies who are born with low birth weight is virtually unchanged over the past decade. Full-term babies born to the most deprived parents are twice as likely to be of low birth weight as those born to parents in the least deprived category.

Low birth weight is not a problem of just being underweight at birth and catching up later on; it can be indicative of many health problems for the individual in future years. Babies of low birth weight suffer poor health in the first four weeks of life in particular and have a higher risk of death before attaining their second birthday. They risk delayed physical and intellectual development, both in childhood and in adolescence. They are more likely than average-weight babies to have some form of disability. Low birth weight is also a significant risk factor for developing asthma and there is now some evidence to suggest that low birth weight increases the risk of heart disease in later life.

Women's health and maternity services in the widest sense need to be a crucial part of any health strategy, particularly in areas of deprivation. That is why it is such a retrograde step to deny the people of Inverclyde, Dumbarton and Argyll a complete consultant-led maternity service. I know that the issue has been raised by other members, including Duncan McNeil, who raised the issue of the Rankin hospital this morning. The closure of the Vale of Leven maternity unit along with its urology and accident and emergency units is nothing more than death by a thousand cuts. The people of Inverclyde also face the loss of their maternity services because of the closure of the Rankin hospital, as has been mentioned. The maternity services are to be centralised in Paisley.

Tackling many of our health problems means making health facilities available locally, not closing them down. Glasgow is about to see the closure of the Victoria infirmary, which is to be replaced by a stand-alone ambulatory care and diagnostic unit. Stobhill is to be downgraded, with the loss of acute in-patient services. In addition, Glasgow will lose three of its five accident and emergency units. All those cuts are taking place against the wishes of the people of Glasgow. Mention was made earlier of the need to talk to people and consult them about health services. That is an admirable aim, but it is no good talking to the people if we do not listen to what they say. I have yet to speak to one person who thinks that the proposals for Glasgow are the best option for patients or their loved ones.

If the Scottish Government is serious about rising to the challenge of improving Scotland's health, it must tackle the causes of ill health and not just the symptoms. First and foremost, that means tackling smoking. If we did what California, New South Wales and New Zealand have done, and what Norway and Ireland are about to do, we would see the same health benefits, not just in relation to cancer rates, but for other smoking-related illnesses. It is not just about smoking; we also have to deal with poor diet. Perhaps most important of all, we must tackle poverty.

I congratulate the Executive on taking the opportunity to hold an open debate on this subject.

I wish to highlight the issue of breast-feeding. In response to something that Kate Maclean said, I point out that breast-feeding received good media coverage last year, which was important in helping to raise awareness and encourage all the people who work so hard in that area. The importance of such media coverage cannot be underestimated.

Despite its enormous potential in providing a wealth of protective health benefits for the population, breast-feeding is frequently neglected—and worse—by society and, regrettably, it is often marginalised in the NHS and, indeed, in health debates in the chamber. I am pleased that the Minister for Health and Community Care mentioned support for breast-feeding in his opening speech. I am sure that members are familiar with the extent of the evidence showing the short-term and long-term health benefits of breast-feeding and its fundamental role in public health. If they are not, I will happily speak to them later—I do not have the time to go into it in detail at the moment.

The link between poverty and ill health has been raised in the debate. Given the direct correlation between areas of higher deprivation and poverty and lower rates of breast-feeding, coupled with the fact that the mothers who have most to gain with regard to their and their babies' health—namely, the young, the poor and the least educated—are the least likely to breast-feed, I suggest that breast-feeding has the potential to serve as a valuable tool in the struggle to reduce health inequalities.

Breast-feeding uptake and continuation rates are increasing, and breast-feeding mothers are benefiting from improved practice and innovative forms of support. That is largely due to the dedication and commitment of health sector workers and the national breast-feeding adviser. Despite those advances, considerable work and investment are still needed to help health sector workers and mothers achieve the Scottish breast-feeding target of 50 per cent of mothers still breast-feeding their babies at six weeks of age by 2005.

Thirteen of the 15 Scottish NHS boards now have breast-feeding strategies in place, but there is no targeted or direct additional funding to assist with their implementation locally. That could ultimately lead to the downsizing or sidelining of breast-feeding promotion in order to accommodate other issues—albeit important ones—and meet escalating costs. The health improvement fund is very welcome, but there are competing demands on it, and breast-feeding often does not get its share. I would like the minister to comment on that.

If, as a nation, we are to initiate the necessary step change in the rate of improvement of health, we must ensure that health promotion and preventive strategies are given the depth of focus and financial support that they deserve. We should identify and build on the exemplary and innovative work that is being carried out by health sector workers at various levels throughout the country. It is essential for the continuation and development of such best practice that health sector workers at the grass-roots level see their efforts being supported financially and built on by the Government.

Although health care workers in my constituency welcome and recognise the potential benefits of the Executive's healthy living campaign, they have expressed regret that that campaign did not highlight the fact that healthy eating starts at the very beginning of life, which is an important point. I am pleased by the Executive's commitment to improve the health of Scottish people, but I share the concern of health professionals that potentially beneficial practices such as breast-feeding seem to be neglected in favour of solutions that are more orientated at achieving immediate results.

The minister said in his opening speech that there was no quick fix or solution. Breast-feeding is not a quick fix. However, more attention and funding towards it could, over the years, result in a much-improved health record among Scots.

Let me turn briefly to "Improving Health in Scotland—The Challenge". One of the actions that is proposed in the document is

"increasing the proportion of mothers breastfeeding, focusing on disadvantaged groups".

I welcome that, but how will it happen? A significant percentage of new mothers who do not breast-feed or who stop breast-feeding cite embarrassment as the reason for that. We need to shift social attitudes.

I ask the Scottish Executive to use the second session of Parliament to take every appropriate opportunity to support the promotion of breast-feeding, to adopt the international code of marketing of breast-milk substitutes and to give favourable consideration to the breast-feeding etc (Scotland) bill when I introduce it.

I offer my regrets to the six members who have not been called in the debate. We move now to closing speeches.

I welcome the type of debate that we have had today. It has been a long day for those members who have tried to listen to most of it, but it has been interesting.

I was particularly interested by Kate Maclean's thoughtful speech about the role of the media and our response to it. Elaine Smith described breast-feeding as not a quick fix. As someone who tried for 10 very sore days to get my son to breast-feed, I can assure her that it was not a quick fix.

I was pleased to hear Euan Robson, the Deputy Minister for Education and Young People, speak in a health debate. It is important that we convey the message that health affects us in a host of ways and must be dealt with more holistically than any other issue. Ministers in all parts of the Executive should interest themselves in it, regardless of whether they are responsible for education, health, housing or transport.

Donald Gorrie made a point about self-esteem, which is at the heart of transforming Scotland's health. Each of us should do what we can to build the self-esteem of everyone in Scotland, no matter whether they come from the mainstream of our community or from minorities in Scottish society. If people do not have self-esteem, that will affect their health and mental well-being. Adam Ingram made a good speech about mental health issues, which we tried to address to a large extent in Parliament earlier this year. Like him, I believe that we must resource mental health care properly. Many of the mental health problems that people have relate to self-esteem. If we do not deal with those, people can experience physical as well as mental problems. We must challenge people's lack of self-esteem across the board—in the way in which we deal with poverty, equal opportunities for our citizens, education and access to services. We need to take an holistic approach.

I am pleased that the minister has acknowledged that Scotland's health is not improving fast enough. There are some signs of improvement, but we still have a poor health record on cancer, heart disease and many other diseases. I agree with a number of speakers who have said that the factor that would make most difference to the lives of smokers would be for them to give up smoking. I am on the fence about whether we should move towards banning smoking in public places—an idea raised by Stewart Maxwell and others—but the matter should be given a proper airing, if I may put it that way. We should examine the arguments for and against the proposal and establish whether there is evidence that banning smoking in public places would make a material difference to the number of people who are dying. In the time that we have taken to debate health today, about 20 Scots—one sixth of our number—have died as a consequence of smoking. Before I have finished, one of them may be Stewart Stevenson.

Most people are complacent about their health. Shona Robison said that, when asked, up to 77 per cent of people say that they are quite healthy. In reality, many people are not healthy. They are living on a time bomb of high blood pressure, poor diet or lack of exercise. We should try to address all those issues as early as possible. Government's role is to make it as easy as possible for people to make good choices about their health.

That is not about banning everything in sight—I am glad that Susan Deacon does not think that we should ban sex—but about ensuring that people have access to services and options that allow them to have a much healthier lifestyle. We should be serious about developing that approach, particularly in relation to men's health, because all the statistics show that men do not go to their general practitioner as often as women do. Nor do they address their health problems to the same extent that women do, partly because women often go to their GP with their children.

Susan Deacon's contribution on sexual health was, as ever, excellent. I agree that it is wrong for the Executive to rule out any part of the suggested sexual health strategy before it has been debated properly and fully by MSPs and Scottish society at large. That might not be a comfortable debate, but that does not mean that we should not have it. There has been an increase in the level of sexually transmitted diseases and we have to be big enough to have a debate about how we tackle that.

It has come through loud and clear in the debate that as well as taking ownership of their health, people have to be encouraged to take ownership of the health service. One of the issues that has come through time and again—particularly in the speeches of Pauline McNeill, Mary Scanlon, Sandra White, Dennis Canavan, Jamie Stone and Paul Martin—is that people in Scotland feel disfranchised in relation to the health service as it is provided at the moment. It is provided for them, or given to them, but it is not what they have said that they want. We have all heard that because of the working time directive, or for other reasons, accident and emergency services cannot be provided at hospitals where people want them, such as the Western general hospital in my constituency.

In the Parkgrove and Clermiston area of my constituency, some GPs decided to cut their surgery hours and thought that they could do so without asking anybody's permission, because they are independent practitioners. We have to find a way of encouraging people in the health service to recognise that ownership of the health service lies with the patient, rather than with the practitioners and clinicians.

A number of key umbrella issues have been touched on, one of which is demographics. As Duncan McNeil said quite rightly, we have an aging population, so we have to deal with the fact that many staff in the health service are approaching retirement. That takes us into a broad range of issues, which I will not bother to go into—

Because your time is up.

Yes, because my time is up. The debate has been useful and I am grateful to have had the opportunity to take part.

I share the concerns that have been expressed by several members about the format of today's debate, important though the issues that we have been discussing are, at a time when there are still serious problems in the NHS that have not yet been addressed by the Executive. However, we have had a wide-ranging debate, which has given many members the opportunity to set out their stalls and to highlight their own particular and local concerns about the health of Scottish people and how it should be improved.

Members have highlighted the widespread difficulty that patients experience in accessing health services in Scotland, although there is no criticism of NHS staff or treatment once they get there. Mary Scanlon spoke eloquently about difficulties in access in the Highlands and Islands and the waiting-time problems that still beset the service despite the large sums of money that have recently been poured into it. Without reform, money will not greatly help the situation. The Executive needs to address that fact with the utmost urgency.

There is clear cross-party agreement on today's challenges to the health of our nation. Those challenges include the need to tackle obesity, coupled with a sedentary lifestyle, which is an underlying cause of coronary heart disease and several common cancers. Other challenges are the proven risks of smoking and alcohol abuse, the need to encourage healthy eating, the promotion of mental well-being and the prevention of sexually transmitted diseases and unwanted pregnancies—a plethora of public health issues, covering the whole spectrum of life from the womb to extreme old age.

Much has been achieved in recent years. The infant mortality rate has been more than halved and survival rates for coronary heart disease, strokes and breast cancer have significantly improved. However, as the minister said this morning, Scotland's health is not improving fast enough and more needs to be done.

I am sure that there is not a single member in the chamber, from any part of the political spectrum, who does not want to improve the health of people throughout Scotland. The differences that we have are in our emphases and how we believe we can best achieve the improvements that we want.

As members know, my party believes in individual responsibility and choice. We believe that the Scottish Executive's approach has too often been to adopt a nannying tone and to centralise control. That comes across to some extent in "Improving Health in Scotland—The Challenge", although to be fair it was not so evident in the minister's opening speech.

We believe that people and patients must be at the core of service planning and that many public health issues are best dealt with locally. I am pleased that the minister stressed the importance of the voluntary sector and community-based action. As Eleanor Scott hinted, some of the advice that comes from NHS Health Scotland is hardly rocket science and the number of glossy campaign documents that come from the Executive is prolific. I wonder whether we are always getting best value for money, or whether some of the resources that are being spent in that way would have more impact at community level, where the effective work is done.

Public health planning is crucial to improving the nation's health, but we must not forget that treating those who are already suffering is of the utmost importance. The reform of key public services is needed urgently to help the most vulnerable in our society, who are most likely to suffer from ill health. David Davidson made plain our approach to a patient-focused health service and I reiterate our commitment that quality and choice in health care should be available to everyone. People who are on low incomes, the increasing elderly population and the large number of dedicated carers, young and old and many who are not yet identified as carers, are all groups whose needs must be considered and who should be involved in health care planning, delivery and evaluation.

I am pleased that Janis Hughes so clearly explained the continuing concerns about the patchy development of carers' information strategies and the need to identify hidden carers. I am also pleased that she paid tribute to the valuable work of the Princess Royal Trust for Carers, which, in the same way as the other voluntary bodies that were described by Christine Grahame and Sandra White, is not adequately funded for further development of the services that it offers to carers. The trust merits more help from the Executive.

We heard detailed comments from Liberal Democrat members about the partnership agreement. From the expressions on ministers' faces during those speeches, I wonder whether the agreement on health issues was not quite so dominated by Liberal Democrat manifesto commitments as we were led to believe.

Frances Curran passionately criticised meaningless public consultation. John Scott drew attention to an on-going consultation in Ayr that looks as though its outcome will be pre-empted by decisions. In my experience, widespread cynicism is generated by that sort of thing. That is why I asked questions last week about the importance of meaningful public consultation. There is serious concern about that issue and it must be sorted out.

Shona Robison covered many issues in her opening speech for the SNP; I will not go into them in detail. We are in agreement with some of what she said, but David Davidson's speech gave a pretty clear indication of where we disagree. Suffice it to say that because we are a unionist party, we are confident that the problems within the NHS do not require independence for their solution.

Adam Ingram rightly drew attention to the stigma that is still associated with mental illness and the need to make the public more aware of it, so that mental illness can be talked about more openly and with understanding. We have seen the benefit of such an approach in recent years with patients who suffer from malignant diseases such as cancer.

Rob Gibson made some interesting comments about problems in the Highlands and Islands and other rural areas that are home to 30 per cent of the Scottish population. Phil Gallie and John Scott told us about the shortage of junior doctors in Ayr. That shortage is due in part to the effect of the working time directive on junior doctors' hours. That is a serious problem throughout Scotland; it is threatening acute care in many areas and it is very difficult to address.

Finally, having worked as a doctor in the NHS in Aberdeen for more 20 years, and having consistently and vocally supported the NHS as a universal service freely available to all who need it, I find Kate Maclean's perception that Tories do not care about patients a little offensive. David Davidson is also a health care professional.

Although public health in Scotland is undoubtedly better in many respects than it was in our parents' and grandparents' time, we now face major health problems as a result of our modern lifestyle: the fast pace of life and workplace stresses that are caused in no small measure by modern technology and the speed of electronic communication; broken relationships; the ready availability of junk food and alcohol; the scourge of drugs; and the demographic time bomb of an aging population.

The challenge is great. As MSPs, we all have a duty to rise to that challenge and to do our little bit to improve Scotland's health.

We have had two announcements from the minister today, and an announcement that there will be an announcement next week. Is that enough to justify an all-day debate without a motion? Well, yes, it certainly allowed a wide-ranging debate, which is excellent. It has enabled many points that would not have come out in any other way to be brought to the chamber. Have we, as members, learned how to use this form of debate to best effect? I suspect not. We still have to learn. The format is still on trial as far as I am concerned.

Across the chamber and across the parties, members have made many points of interest, some of which were local and some of which were of national concern. The challenge for the Executive is to show that it will respond to this form of debate. Of course, the Executive cannot respond positively to everything that has been said, because it does not all agree with itself, although there is much agreement round the chamber. I hope that ministers will reflect on those remarks, because, if they fail to respond, not just the Executive will suffer public opprobrium as a result of this debate format, but the chamber as a whole.

On that point, I will have sat here for 4 hours and 20 minutes but have had no opportunity to represent senior citizens in today's debate, which is shameful. It would not take rocket science for the Presiding Officer to curtail everyone's time slightly to give us all a chance to participate.

Order. That is not a point for Mr Stevenson, but a point for me, which should have been raised as a point of order. This chair will not dispute in the chamber the choice of speakers or the allocation of time. I make the observation that we reduced the time for speakers in the afternoon. Seven members asked to speak and were not called—I forgot about Mr Sheridan earlier. No matter how we had handled the debate, there is no way that we could have shoehorned in an extra seven members.

I am sympathetic to John Swinburne's attempt to bring the issues associated with older people to the chamber. Members around the chamber have raised such issues. I am reaching a point where, not too long from now, I might be a pensioner as well.

We discussed money as part of today's debate. We keep hearing that there is more of it in the health service, and I believe that—money is going from the Executive's balance sheet and into the health service—but all of us have experienced meetings with health service professionals who say, "Well, that's fine, but where's the money? What's it doing? It doesn't seem to be reaching me."

At First Minister's question time today, my leader John Swinney raised the private finance initiative, which is only one of the clues to what is actually happening. The costs of PFI are considerable. There are many models for bringing the private sector to bear on public projects. The French in Napoleonic times had la concession, which was used to build the canals. The private sector built them, and the public sector committed to buy them after they were built. There are different models around the world.

The real point is that few schools are built by council brickies and few hospitals are built by NHS staff. The private sector is in there. It is not about who does the building of things, but about the diversion of NHS money into the banks' coffers and profits. My mortgage interest rate is about 4 per cent per annum. PFI projects borrow at around 8 per cent, with mezzanine finance at rates up to 14 per cent. Why is that so? My old boss, who was a bank chief executive from the local area, told me that with the SNP's trust model he would lend to trusts in the public sector at three sixteenths of a per cent over bank base rate, provided that the Government provided a guarantee. The cost of that guarantee would be approximately 5 per cent of the total project fund, which is more or less the difference between the first year's interest payment in the trust model and the interest payment in the PFI model. That is where some money is going. The Executive must open its mind on that issue.

I will deal with the operation of the NHS, because the debate is not all about money; it is really about patients. Some people appear to have suggested that NHS staff do not care about patients and do not put patients first. I do not meet such staff; I think that all NHS staff believe that they put patients first and want every opportunity to do so.

The public bring two subjects in particular—the health service and schools—to MSPs, because we have personal experience of them. I have a number of communications on school issues, but the public's view is increasingly that the health service is in poor health, like many people throughout Scotland.

We will not improve the health of people unless we improve the quality of our health service. The Minister for Health and Community Care courageously accepted that, in cancer services at the Beatson, we had to do more, and he addressed himself to doing so. I thank him for doing that, which is exactly what we want. That is some progress, and I say conditionally that we are moving in the right direction. However, it might be too little, too late. Consultants are resigning from the health service in areas that have particular pressures and shortages. When that happens, we are on a downward slope, because it becomes difficult to recruit more people.

I will focus on dentistry, about which one or two members talked and in which I have a special interest. Manchester has one dentist for approximately every 1,000 people and Edinburgh has one for every 2,000, but rural north-east Scotland and the Highlands and Islands have one dentist for approximately every 4,000. That shortage means that lists for NHS patients are all but closed in the dental service. In some towns, even private dentists cannot take new patients.

What does the Government know about the dental service? Does an NHS dental service exist at all?

Will the member give way?

I do not have time; I have another eight pages of notes for my speech.

I have asked a series of parliamentary questions about the dental service. In question S2W-2355, I asked how much NHS dentists earn. The Government does not know. In question S2W-626, I asked how long people must wait to join a dentist's list. The Government does not know. In question S2W-625, I asked how many people are on a waiting list to join a dentist's list. The Government does not know. In question S2W-2356, I asked how many foreign dentists are working temporarily in the NHS. The Government does not know. In question S2W-2352, I asked how far patients must travel for NHS dental treatment. The Government does not know. The most astonishing answer is to question S2W-2353, which asked how many dentists are working in the NHS. The Government does not know.

The golden hello scheme was designed to bring more dentists into the health service and pays up to £10,000 for three years in some circumstances. The scheme has been such a success that six golden hellos have been approved. One golden hello has been given in Forth Valley NHS Board's area, two have been given in Lothian NHS Board's area, and the initiative has also been used in the Greater Glasgow NHS Board and Dumfries and Galloway NHS Board areas. However, no golden hellos have been received in Grampian NHS Board's area or Highland NHS Board's area, where the greatest pressure is felt. Do national dental services exist?

That situation affects not only dentistry. Scotland has 50 GP vacancies. Despite health board efforts and additional funding, will our remoter communities find themselves in a similar position in which we do not have the people to do the job and services cannot be delivered?

Ministers should think about social conditions. People who are captured by tobacco or other drug addictions will continue to suffer at the hands of those who exploit their compelling needs. Alcohol abusers will continue to suffer and to inflict suffering on others.

The Parliament has the power to empower patients and practitioners and to provide funds that can liberate our health service from the dead hand of overcontrol. Indeed, that is the consistent message that my colleagues and I constantly receive.

Although we can get better on the money that has been provided, we can get more for that money if we moved a little bit away from PFI. However, we need a successful economy in a successful country before we can solve the deep-seated problems that underlie the health service and so much else in Scotland. That means being a normal, independent country.

This country faces many health challenges. Although in many respects we have come a long way, we need to go considerably further if we are to change behaviours and lifestyle choices, which are the two issues that lie at the crux of today's debate.

We have spent a longer than average time today examining the shortfalls of our health outcomes, and there have been some excellent speeches on that matter. However, we have perhaps also demonstrated that we still need to establish the critical distinction between health improvement and promotion and concerns—understandable though they are—about the daily operation of the NHS.

Today we have discussed the health improvement challenge as a subject of critical importance, without the posturing that all too often accompanies motions, countermotions and amendments. Furthermore, we have signalled that the principles of consensus that are embedded in the consultative steering group report can encourage us to transcend the differences of view that often divide us along party lines. In all candour, after more than four years in the chamber, I have seen little evidence that contentious motions ever focus debate and much evidence that they focus on unnecessary division.

We believe that the partnership Executive's policy direction can achieve a substantial improvement in the habits and lifestyle choices that ultimately determine our health outcomes. However, I have no intention of hiding behind consensus or our achievements so far, pretending that all is well or that we have all the answers. All is not well. We have a very long way to go and no single group, no matter how important or powerful it is, has all the answers. If ever we needed to translate the much vaunted concept of partnership working into tangible, quantifiable outcomes, it is when we seek to influence behaviours that lead to health improvement.

In his speech, my colleague Stewart Stevenson asked how the Executive intended to respond to this form of debate, given the range of suggestions that have come from members on all sides of the chamber. Will the minister now answer that question? How does he intend to respond to the debate?

I hope to do so over the next 13 minutes.

During the debate, members have referred to some of the critical areas that we must address such as smoking, diet, alcohol abuse and a lack of physical activity. They were right to do so and I will deal with each area in turn. However, first I want to acknowledge that there have been successes and that they have been achieved by an army of committed public service workers who have shown a dedication to their task. Leisure attendants, social workers, doctors, nurses, teachers and so many other public sector workers all play a part in improving our nation's health. Every one of those individuals deserves clear leadership from the First Minister, the Cabinet, the entire breadth of the Scottish Executive and chief executives and senior managers across the public sector. Consistency, persistence and direction from those in a privileged position to shape policy will produce results and reward those hard-working individuals.

Apart from those whom we can readily identify, there are others who make an invaluable contribution. Before this debate was scheduled for today, I was due to meet carers and carer representatives from Fife. Obviously that meeting has had to be rearranged; however, I am glad to say that they decided to join us in the public gallery and I place on record once again just how much they contribute to the health and the vital fabric of our society. [Applause.] We have placed new duties on local government to identify and provide a needs assessment for carers and, indeed, to identify carers themselves. We will continue to demonstrate that we value their contribution and I hope that they take some encouragement from our debate today.

I will now turn to the four areas that I mentioned earlier. It has been said time and again, but it is worth repeating that smoking is the single biggest cause of preventable death in Scotland. On the journey towards premature death, smoking causes misery to the victim and to those who have to cope with the consequences and inflicts a remarkable cost on our economy in general, and on our health service in particular. I hope that Malcolm Chisholm's announcement of a further £1 million for smoking cessation will be warmly welcomed, especially as it will be targeted at the most deprived communities.

In the near future, the Executive will launch the new action plan on tobacco control. It is our sincere hope that the document will enable us to chart a forceful and successful course for our tobacco control policies. I assure the chamber that, even in a spirit of consensus, we will pay no heed to David Davidson's notion of "sensible smoking".

Alcohol is widely used and enjoyed in Scotland. Drinking small amounts of alcohol is compatible with a healthy lifestyle and can confer health and social benefits. However, drinking too much can lead to serious illness, accidents and antisocial and criminal behaviour. As too many people in Scotland know only too well, alcohol abuse can tear apart relationships and destroy families. Perhaps we have taken for granted its negative impact on our society for too long.

The document "Plan for Action on alcohol problems" was published on 18 January 2002 and sets out a range of national and local action to tackle alcohol problems in Scotland. The overall purpose of the plan is to reduce alcohol-related harm in Scotland, and the key priorities are to reduce binge drinking and harmful drinking by children and young people. However, changing attitudes will not be achieved overnight.

My deep interest and commitment to the issues are well known by some people. I now chair the Scottish advisory committee on alcohol misuse. As Malcolm Chisholm mentioned, next week I will launch a Scottish intercollegiate guidelines network guideline on the management of harmful drinking and alcohol dependency in primary care. As Malcolm Chisholm also mentioned, our partnership agreement commits us to increasing resources for treatment services within our communities.

That is an area in which we know that we need to review and update our thinking, and parties across the chamber can play a part in that process.

After smoking, poor diet is the most significant contributor to poor health in Scotland. The Scottish diet is characteristically high in fat and low in fruit and vegetables and, although recent statistics have shown that it is getting better, improvements are not happening fast enough.

The Scottish diet action plan is one of Scotland's best developed and most mature health improvement programmes. The plan is being implemented on a sufficient scale and with sufficient energy to have a realistic prospect of producing measurable improvements over the next five to 10 years.

One example of our commitment to changing Scotland's culture of poor eating habits is the high-profile national healthy eating campaign, healthy living, which was launched in January. The campaign aims to increase demand, skills and confidence in relation to healthy eating, through an advertising campaign, a telephone advice line and an informative website.

There are positive developments on breast-feeding, which was mentioned earlier. We now have a national breast-feeding co-ordinator and the highest rate of participation in the UNICEF UK baby friendly initiative—over 85 per cent.

Last week, we debated the growing problem of obesity in Scotland. We recognised the vast array of other serious conditions that can arise as a consequence of obesity. The Food Standards Agency is currently conducting a systematic review of the impact of mass advertising by large food retailers. That kind of empirical evidence will help us to develop the most appropriate responses to the serious condition that is obesity.

Improved levels of physical activity are key to reducing early deaths from coronary heart disease, cancer, diabetes and obesity. The establishment of the physical activity task force marked the first step in the development of a strategy for physical activity in Scotland and brought together the right people, with the right expertise and knowledge, to co-ordinate planning that will increase levels of physical activity across all ages. Physical inactivity is a serious risk factor in Scotland and we need to face up to that reality.

The strategy outlined in "Let's Make Scotland More Active" signals a new national direction for the Scottish Executive in relation to physical activity. Its mainstreaming into health improvement signals our commitment to raise awareness of the strategy immediately and to accelerate action. Immediate and sustained action across portfolios will be needed to increase physical activity levels.

I think that Nicol Stephen gave an undertaking that the Executive would consider free swimming lessons in Scotland's primary schools, but I cannot recall what happened to it. I know that many local authorities—almost half of them—opted out, but I am not sure what the current position is. What happened to that undertaking?

I do not have information about the extent to which free swimming lessons are available throughout Scotland. Many local authorities have adopted policy positions that make lessons available for children and elderly residents, but I do not know whether such lessons are available across the board in Scotland. I will make efforts to obtain the figures and forward them to the member.

A long-term approach—up to 20 years—is required to increase physical activity levels, but work is under way to develop five-year action plans for homes, communities, schools and workplaces. The Executive takes health improvement seriously and I hope that this full-day debate signals our intention to move the issue further up the political agenda. I hope that it also signals our willingness to listen to the views of others.

I welcome today's debate and what the minister has said. However, does the minister agree that Dennis Canavan's speech about an acute hospital review and his unjustifiable remarks about Anne McGuire and controversial issues relating to land sites in Stirling were not helpful in an otherwise very good debate?

On a point of order, Presiding Officer. I stand by the accuracy of every word that I said. If I referred to any untruths, they were the blatantly false statements that a UK Government minister, Anne McGuire, gave to the Stirling Observer on a devolved matter, which a UK Government minister should not do.

That is not a point of order, Mr Canavan, and you know that it is not.

I am not in a position to make informed comments on what was or was not said in the local press in Stirling. However, I said earlier that, as parliamentarians, we need to make the distinction between the drive to achieve an improvement in Scotland's health outcomes and the genuine concerns that exist over the day-to-day management of the NHS.

I said that I hoped that today's proceedings would signal our willingness to listen to the views of others, so I am glad to announce that we will establish a new joint ministerial steering group on health improvement, which I will chair. I will be joined on that group by another non-health minister, political representatives from the Convention of Scottish Local Authorities, the chair of NHS Scotland and the chair of a health board, to name just a few. The group will be supported by a stakeholders group. I intend that it will hold its first meeting no later than November this year. Our intention is to make a formal announcement in the near future that will provide a fuller explanation of the group's remit and membership. The aim is simply to provide the direction that will forge the necessary partnerships throughout the public sector and to develop an acceptance among the range of influencers in the public sector that they can and must share responsibility for changing attitudes and for the health prospects of those whom they serve.

I made it clear during the debate on obesity that there is no room for complacency—I stress that again today. We need to attach greater urgency and priority to health improvement. Much has been said about the link between deprivation and poor health outcomes. We need to believe that health creates wealth and that wealth creates health. We fully recognise that when we create economic opportunities, expand horizons and give people solid reasons to change their lives, we will succeed, and we firmly intend to succeed.