Primary Medical Services (Scotland) Bill
The next item of business is a debate on motion S2M-698, in the name of Malcolm Chisholm, that the Primary Medical Services (Scotland) Bill be passed, and two amendments to the motion.
I am delighted to open this final debate on the Primary Medical Services (Scotland) Bill. This important legislation will impact on every person in Scotland and I am pleased to note that the bill's principles have been accepted by Parliament from the start of its passage.
In commending the bill to Parliament, I think it only right and proper that I pay tribute to those who have been involved in its progress. First, I thank all of those who have been involved in discussions on the bill, including groups from outside Parliament who took the time to come and give evidence to the committees. The bill will affect everyone who accesses primary care, so I am pleased that Parliament was able to hear the views of doctors—through the British Medical Association and the Royal College of General Practitioners—and of patients, through the Scottish Association of Health Councils and the Scotland Patients Association.
I am also grateful to the members of the Health Committee, the Finance Committee and the Subordinate Legislation Committee, all of whom worked hard to scrutinise the bill within what I accept was quite a short time frame. In particular, I thank the members of the Health Committee, whose desire to understand the detail of how the new contract will work has been an example to us all. During the stage 1 debate, the committee convener suggested that I was having nightmares about the regulations. I hope that the draft regulations that we have now shared with the committee are providing Christine Grahame with some light bedtime reading rather than causing her sleepless nights. Finally, I want to thank the clerks of the various committees and—last but not least—our wonderful bill team.
This bill represents significant modernisation of the way in which primary medical services will be delivered throughout Scotland and will improve the working lives of doctors and practice staff. Even more important, it will improve things for patients. In many ways, primary medical services are the front line of the national health service. As more than 90 per cent of patients' experiences with the NHS begin and end with primary care, it is essential that we have a strong, modernised system of delivering primary medical services to the people of Scotland.
As we modernise how primary care services are delivered, I want to ensure that they are delivered in modernised up-to-date premises. Patients have already seen, and are using, new and improved premises throughout Scotland, which have benefited from the Executive's modernisation programme. That development has meant better service delivery and more accessible services for patients.
Today, I am pleased to announce a further £19 million investment for primary care premises throughout Scotland, which will be used to deliver more services in primary care settings or to bring together primary care and social care services. That investment will build on the £51 million that has already been spent on updating and modernising primary care premises.
Will the minister share with us the areas of primary care towards which the money will be directed?
I will say more about that in a moment. Indeed, at this point, I will say that I want patients to continue to benefit from the programme. As a result, £4 million of the money that I am announcing today will pump-prime the development of the community health service centres that are described in the partnership agreement. Those centres help to bring together treatment, diagnosis and support services in a single centre. The funding will also help rural areas to develop outreach facilities using information technology and video-link technology. The development of community health service centres and the investment in remote and rural areas will ensure that a wider range of services is available in communities.
The second part of my answer to David Davidson's question is that the remaining £15 million will be available over two years, starting in 2004-05, to provide top-up funding to joint working projects that have been agreed between NHS boards and their partner local authorities.
There are already a number of good examples of such joint working. For example, at the Dalmellington resource centre in East Ayrshire, patients can access from the same building not only general practitioner, practice nurse, community care and mental health services, but a wide range of local authority services. That type of joint working is very much in the interests of the patient and I am delighted to be able to provide additional resources to allow such an approach to spread across Scotland.
The bill is not about privatising primary care. Indeed, we have already debated that issue at some length at the bill's previous stages. I am pleased that Parliament has accepted the Executive's views and rejected the Scottish Socialist Party's suggestions. I want to reiterate my position one more time—GP practices that provide services under the current arrangements will continue to do so in the new world. Big private companies will not be able to hold a general medical services contract.
The provision of out-of-hours care is already changing. People who pick up the phone at night in many parts of Scotland find that their call is not answered by their own GPs. Everyone agrees that a tired GP who has worked all day should not have to work through the whole night. Many GPs have formed co-operatives to share the burden of out-of-hours care. Moreover, we have set up NHS 24, which is a confidential 24-hour nurse consultation telephone service that is available to everyone in Scotland for the cost of a local call. We will build on these changes for the new system and people will still have access to help, advice and treatment whatever the time of the day.
Does the minister understand that GPs in the Highlands are having to make very difficult—indeed, agonising—decisions about opting out of out-of-hours commitments to their patients because of uncertainty about what is being put in place for their patients?
Tom McCabe will deal with that issue in some detail in his closing remarks. However, a report will be published today by the group that has been carrying out work on out-of-hours services. Members might want to read that detailed report, because it describes some of the models that are being developed. The group has been set up to share some of that good practice and to work alongside NHS boards to come up with solutions.
I should also say that Mary Scanlon knows about the difficulties of recruiting and retaining GPs in rural areas—the contract will be a great benefit in that respect. As I said, Tom McCabe will make other points on that subject when he closes.
The bill is not about removing services. Patients will still be able to go to their local GP practices for the vast majority of their needs. As far as more specialised needs are concerned, people might have to go to a different practice if, for example, their doctor does not provide minor surgery. However, they will still be able to access such services in a primary care setting instead of needing an out-patient's appointment at their local hospital, which is perhaps what happens at present.
Patients will not be left to find their way round the new system on their own. Practices and health boards will have to ensure that patients are helped to access the full range of primary medical services. I am happy to repeat that key commitment today.
The bill seeks to empower GP practices to recruit the right mix of people in order to provide high-quality services to patients. Under the new contract, funding will follow the patient. Practices will receive funding for the services that they provide, not for the number of GPs in them. Moreover, they will be able to decide how to use funding to recruit and retain the right mix of staff for those services. That approach recognises the unique contribution that nurses and other health care professionals can bring to general practice, and will free up GPs' time to allow them to carry out the work that they are trained to do.
By offering more opportunities for GPs to work flexibly, the bill seeks to make general practice an attractive career option for the next generation, and to retain GPs who already provide such a high level of commitment to the NHS. It will also make it easier for them to move in and out of salaried and independent contractor status. With that measure and a new portfolio approach to career development, GPs will find it easier to adapt their careers to suit their aspirations.
The bill is about safeguarding and developing services in rural areas as well as in our towns and cities. The whole bill and the contract are designed to aid recruitment and retention in all parts of Scotland. However, the contract tries to address specific remote and rural issues.
The new Scottish allocation formula—used to allocate the global sum to practices and the enhanced service floor, and board-administered funds to health boards—will directly benefit remote and rural areas. The Scottish allocation formula reflects the additional costs of providing services in remote and rural areas and ensures that practices in those areas receive proportionally more than practices in urban settings. Rural boards will also receive proportionally more to help with the costs of providing enhanced services and with expenditure on, for example, premises and information technologies. I hope that that reassures members that GP practices and patients in rural areas will benefit from the new arrangements.
The bill is about ensuring that resources follow the needs of patients. Under current arrangements, money follows the doctor, so the more doctors there are in a practice, the more money there is. If a GP leaves, the income of the practice reduces. That will not happen in the future.
Of course, the bill is part of a much wider modernisation agenda. We are also improving contracts for consultants and for nurses and support staff through the agenda for change. Neither of those contract changes will require primary legislation, as members may be relieved to hear, but they demonstrate our commitment to creating a modernised pay system across the NHS. We need to reward the actual responsibilities that staff take on rather than the job title that they work under. We need to offer the prospect of higher inclusive salaries rather than rely on expensive, outdated and inflexible special allowances. We need to provide flexibility so that jobs can be designed to suit patient needs rather than with rigid demarcation lines on what staff think they are allowed to do. The bill will help to introduce those changes for those staff who provide primary medical services.
The bill will also link into other changes that will be brought in by the National Health Service Reform (Scotland) Bill. That bill will allow community health partnerships to evolve from local health care co-operatives. In relation to the general medical services contract, community health partnerships will play a key role in working with NHS boards to identify service needs, particularly those in the enhanced categories. As I said in the stage 1 debate, community health partnerships will then work with local practices and other providers to ensure that those services are delivered most effectively within each community health partnership area. The involvement of community health partnerships will also ensure that we take a broad, multiprofessional and multi-agency approach to provision of services. It is in supporting the development of new services in local settings and in supporting the shift from hospital-based care to community-based care that community health partnerships will come into their own.
Let us remember: if it can be done in primary care, it should be done in primary care. Services should and must be organised around the needs of patients, not for organisational convenience. Services should and must be organised in a way that ensures that resources are marshalled appropriately for the type of care that is necessary and in the right place, at the right time. Some services that have been traditionally provided in hospitals can be provided in the community; we will look to community health partnerships and the new GMS contract to promote that shift in activity.
I will listen with interest to the speeches from Shona Robison and David Davidson on their amendments to the motion. I am sure that Tom McCabe will provide a detailed response once he has heard their speeches, but I would like to make some general comments about why I think the amendments should be rejected.
I understand the sentiment behind David Davidson's amendment, but it is unnecessary. In the stage 1 debate, I said that I was confident that we would be able to share drafts of the GMS regulations with the Health Committee before the end of November. I am pleased to say that my confidence was not misplaced. Copies of the regulations were sent to that committee on 24 November and the following day Tom McCabe appeared before the committee to discuss them. We have further undertaken to provide another draft to the committee before the final version is ready to be laid. I am happy to repeat that undertaking today.
Shona Robison is concerned about out-of-hours services in relation to rural practices and single-handed GPs. I should perhaps point out that those are not necessarily one and the same. For example, a large number of GPs in Glasgow are single-handed practitioners; I cannot see that they will have any difficulty in transferring their responsibility for out-of-hours cover should they choose to do so. More fundamentally, any GPs who cannot opt out will receive additional funding. Tom McCabe will have more to say on the detail of that.
For the past 60 years, GPs have been at the heart of the NHS, but the NHS is changing and it is only right that general practice changes with it. The bill will help to achieve that. There is much in the bill for GPs, but there is even more for patients and for the whole NHS. That is why we introduced the bill and have supported its passage through Parliament. I am grateful for Parliament's recognition of the key principles of the bill. The Health Committee supported our changes at stage 2 and we have had had some interesting discussions today at stage 3. I now ask Parliament to approve the bill and allow us to begin to implement the benefits that we all agree it contains.
Accordingly, I move,
That the Parliament agrees that the Primary Medical Services (Scotland) Bill be passed.
I thank those who came to the committee to give evidence, and I thank the Health Committee clerks, who always keep us right when we are dealing with a bill of this nature.
I start by restating that I believe that the thrust of the bill is not about privatisation, but about trying to resolve the GP recruitment and retention crisis. However, it is interesting to note that a person who did not vote for Carolyn Leckie's amendments was none other than Tommy Sheridan himself—perhaps he had a road-to-Damascus conversion during the speeches, which made him see the light. We can only hope so.
We have said on a number of occasions that we should not underestimate just how great a crisis is being faced in the GP profession, in which there is an aging work force and low morale. That is why the legislation will be so important in trying to turn that around. However, the backdrop to the bill also involves training of general practitioners and some concerns remain, despite the bill. One of those concerns is about the lack of training places for students in Scotland, and of funding to go with them. That issue was raised by general practitioners and their organisations, and by others who expressed concerns. If we cannot produce enough GPs through our training system, we will not be able to solve the problem in the long term. The jury is still out on whether enough is being done to achieve that.
I turn to the amendment in my name. The focus of a lot of the evidence to the Health Committee and of the concerns that were raised was on rural practices and GPs who are unable to opt out of the out-of-hours services. That is obviously where some of the biggest pressures on recruitment and retention fall. There are still areas of Scotland that cannot get GPs to go there and provide services, and there are still concerns about the need to address that problem. It is important that assistance is secured, and I welcome the additional funding for GPs in that situation. I do not know whether that will be enough to attract GPs to remote and rural areas; the jury is out on that question, too. I felt that it was important to restate in an amendment to the motion the principle that we must provide assistance for recruitment and retention of GPs in rural areas.
Primary care is definitely the way forward to delivering services to the people of Scotland. It is the way forward in trying to turn around the state of the nation's health. I welcome the investment that has been announced today, but I expect primary care to deliver much over the next few years. We have huge expectations of community health partnerships and what they will deliver. The SNP certainly hopes that the investment will be enough and that such partnerships will be a success.
We have discussed our concerns, but I am happy to support the bill.
I move amendment S2M-698.1, to insert at end:
"but, in so doing, is concerned that rural practices unable to opt out of out-of-hours services will have serious difficulty in recruiting new doctors and therefore believes that it is imperative that the Scottish Executive ensures that NHS boards honour the principles of the Patient Services Guarantee in all areas, in particular in securing assistance for single-handed GP practices in the provision of out-of-hours services to remote and rural Scotland."
The bill is one of the most important in a long time to help to improve access to health care in Scotland. It has become obvious, to the Health Committee and to many members, that GPs, patient groups, community councils and individuals have been concerned for a long time that the bill should make general practice attractive, that it should lead to an increase in staffing levels in local surgeries and that it should mean that the experience of existing GPs is retained. Many of those GPs are seeking early retirement because of a crisis in morale, the amount of bureaucracy that is involved and, in many cases, overwork. Such experienced people need to be kept in place so that new practitioners can be brought in who can work with them. That will enable new practitioners to develop more quickly and play their full role in providing health care.
There is an issue relating to what happens with young doctors who are trained in Scotland. We produce far more doctors than we retain. The bill recognises that and I think that all parties welcome the fact that it does so. It is important that young doctors who come here to train should want to stay, practise and contribute to the health of the Scottish people—and not just in urban areas.
There is a particular concern about problems in rural and remote areas. Rural and remote practitioners are still concerned as to whether transition systems for funding will allow them the critical mass to keep going. My biggest concern is whether health boards will be able to deliver the out-of-hours cover or general time-off provision needed by rural and remote practitioners, not only to stay happy with their work, but fit for practice. It is important that we recognise the loads that are placed on rural and remote practitioners and the stresses that many face in working alone. I am not yet convinced that the minister can give us a clear statement that all health boards will be in a position to provide such back-up and service by a certain date.
I am happy that the minister commented on the models that are being considered. To be frank, NHS 24 is not a substitute for access to a GP if a matter is essential, particularly in a rural and remote area when time might be of the essence in acquiring medical care.
I lodged my amendment as a result of concerns in the committee. The minister has voluntarily, and without too much coercion, appeared before the committee and discussed draft regulations, but there have been concerns. The British Medical Association was recently concerned that the committee's seeking access to sight of the regulations, through a democratic process, might delay the implementation of the bill. I am happy that the BMA has changed its view and understands that the committee does not and never did want to go down that route. We wanted to scrutinise the bill to ensure that the bill's ultimate objective—improvement of access to medical care in primary services in all parts of Scotland—is achieved.
I lodged the amendment to formalise the proposal that the minister would put draft regulations before us. I thank the minister for what he has done so far, but there is still a long way to go before regulations are laid before the Parliament. If the minister is prepared to give a guarantee today that all changes to regulations will be considered by the Health Committee before they are laid before the chamber, I will not press my amendment. I wonder whether the minister will comment on that matter now. Obviously, he will not.
My amendment is meant to be apolitical and practical. It enshrines the principle of the Parliament that every piece of legislation that affects the life of anyone in Scotland should be seen and approved though the parliamentary process. I would worry if we were to rely only on good will in such matters.
One or two points that the minister has made have raised concerns. On the additional and welcome £19 million for practice premises, I am concerned about whether dentists and pharmacists throughout Scotland will be able to participate in what has been proposed. Such concerns are partly to do with disability access, but also relate to the provision of some new services that the minister thinks are required.
In general terms, the Conservative party welcomes the bill, although we still have concerns about the ability of various organisations to deliver things. As a result—and since the minister is not prepared to give the guarantee that I requested—I move amendment S2M-698.2, to insert at end:
"but, in so doing, expresses concern that the delivery of the objectives of the Bill requires scrutiny of all draft regulations by the Health Committee before they are laid before the Parliament."
I have guidance for members who wish to speak later. It is difficult to work out timings for the rest of the debate. The principal parties in the chamber have been consulted and it looks like the debate will continue beyond First Minister's question time and question time this afternoon. Therefore, I anticipate that I will offer those members who have moved amendments the opportunity to make closing speeches after question time. Thereafter, Mr McCabe will conclude the debate—he will have the opportunity to make detailed responses to points that have been made, as Mr Chisholm said that he would. Before midday, I hope to call all other members who have asked to speak, but if any member is not called before then, there should be enough time after 3.10 pm to call any member who has not been chosen this morning.
The Primary Medical Services (Scotland) Bill is an important part of the reform process in the NHS in Scotland. It includes major changes to how NHS services are delivered. First, there is a duty on NHS boards to provide services throughout their areas. Secondly, there will be a practice-based contract that will help to develop the multidisciplinary approach that is needed in the 21st century. Thirdly, as I said earlier, the proposals are backed up with huge increases in resources to ensure that the new system works better.
At stage 1, I was concerned about the bill on two counts. First, I was concerned that single-handed GP practices in remote and rural parts of Scotland would be penalised by the proposals. The minister appeared before the committee and gave assurances that no current practice would be worse off and, indeed, that the vast majority would be better off under the system. Secondly, I was concerned about the bill's being an enabling bill and that the details of the new contracts would be in regulations that the committee could not amend.
In the previous session, my first experience of such a process was with the National Parks (Scotland) Bill, which was also an enabling bill. The formation of the actual national parks was left to unseen regulations. That experience was not satisfactory. There is no doubt that the Parliament would not have voted through unamended the new Cairngorms national park boundaries. Parliament had the choice only to accept or reject the regulations and we reluctantly accepted them.
With the Primary Medical Services (Scotland) Bill, the Health Committee requested from the minister sight of the Scottish and United Kingdom draft regulations before we considered the bill further at stage 2. If any amendments were needed to the bill, we could therefore lodge them then.
The ministers—Malcolm Chisholm and Tom McCabe—went out of their way to oblige the committee. They produced the draft regulations that we requested as quickly as possible. That was a remarkable achievement. I recommend such an approach with other enabling legislation.
The amendments that we are discussing are unnecessary. In particular, now that David Davidson has heard the minister repeat his commitment to bringing the redrafted regulations before the committee before they are laid, I hope that he will seek to withdraw his amendment—that would be the most appropriate thing to do. By forcing a vote and being defeated on the issue, he might undermine the whole process that he intends to support. I ask him to think about the matter carefully before he forces a vote.
I made the minister a genuine offer to withdraw my amendment if he gives a guarantee in the chamber, for the record, that all regulations or potential amendments that might affect the bill will go to the Health Committee before they are laid before the Parliament. He has not yet chosen to give such a guarantee.
I understand that, but we have not yet heard the minister's summing up. I see that the Deputy Minister for Health and Community Care is nodding.
The Health Committee was criticised in some quarters for its stand on the bill, but we were not prepared simply to rubber-stamp a UK-wide deal. There was some mischief in the press, as it was suggested that the committee would somehow delay the implementation of the bill. No delay has been necessary, so such comments were unfounded. The committee was entirely right to ensure that the legislation that came before it was properly scrutinised—it was the committee's job to do that and the committee did its job.
I welcome the opportunity to participate in today's debate, at the end of what has been another very busy year for the Health Committee. I thank the clerks and all the parliamentary staff who have been associated with the committee for the work that they have put in over the past 12 months.
The Primary Medical Services (Scotland) Bill contains much that is to be welcomed. As we heard, more than 90 per cent of patient contact with the NHS begins and ends with the primary care team, and 87 per cent of that work is dealt with entirely by the primary care services. The improvement and expansion of health care in the community must therefore be a key priority for the Executive.
During the passage of the bill, much press coverage was given to the committee's desire to see the draft regulations that would underpin the new GP contracts. Health Committee members were contacted by a number of GPs, who expressed concerns that any hold-up in implementing the new contracts would have a devastating effect on general practice in Scotland. I was reassured by the minister's commitment, which he honoured, to show us the regulations before stage 2 and I am delighted that, if the bill is passed today, there will be no hold-up in the establishment of the new contracts in Scotland.
The proposed legislation delivers for patients and for staff. The new GP contract will offer patients more choice, better quality of care, new ways of accessing services and greater access to services in the local community. The provisions will allow GPs to control their work loads better, while offering them rewards for delivering high-quality services. That is necessary if we are to encourage new recruits to the profession.
I hope that there will be real investment in the modernisation of health centres. The new Rutherglen primary care centre, in my constituency, is a fine example of a modern, integrated health care facility. We should strive to achieve that standard in every area.
We have come a long way since the time when GPs were the first and only primary health care providers. Optimum care is now provided by a large number of health personnel, including the Scottish Ambulance Service, NHS 24, community nurses and allied health professionals.
Like other members, I was somewhat surprised that Carolyn Leckie lodged her amendments at stage 3, given their overwhelming defeat at stage 2. Carolyn Leckie asked today for yes and no answers, but I say to her—as one health professional to another—that medicine is not an exact science, as she knows. We are not dealing with an ideological issue that has black and white answers. Carolyn Leckie should accept defeat, especially now that that defeat has been endorsed by the Parliament.
The bill represents another good piece of legislation that the Parliament has produced. Much work has yet to be done by the large number of people who will be involved in the negotiations that must take place before April, when the new GP contracts will be implemented in full. By passing the bill today, we will enable those people to move on with that work. I offer the bill my full support and urge the Parliament to pass it.
I associate myself with other members' remarks and thank the clerking teams, the Scottish Parliament information centre and members of the Health Committee.
Members of the committee scrutinised the bill and raised the spectre of regulations—which I look forward to enjoying when I cannot get to sleep at night. The minister kindly sent the committee a letter on 15 December in answer to our letter about regulations and I will pick up on one or two rather technical points that arise from that.
The first issue, which was raised at a committee meeting by Janis Hughes, is with regard to informing patients when a practice opts out of certain elements. In the minister's letter, he says:
"There is no … duty on Health Boards"
to inform patients that a practice has opted out of additional services. He proceeds:
"However, work on a further set of regulations will soon begin to prescribe the information that a Health Board must publicise".
He states that those regulations are being drafted and that they will be ready early in the new year. In line with David Davidson's comments, I hope that the minister will give an undertaking that the committee will have the opportunity to consider the new regulations—that would resolve the issue. I thank Tom McCabe for coming before the committee with his officials to give us advice on the regulations.
The second issue, which I raised, is third-party rights. The draft regulations narrated that no third party would have a right arising from the bill, because the bill simply puts a contract into statutory form. I understand the law of contract and that it is not usual to have third-party rights within contractual terms. However, I am still concerned about what the minister's letter says regarding a person who has been removed from a GP practice list, how that is done, how the person will know about it, and how they can appeal—I use the word "appeal" loosely.
In the minister's letter to me, as convener, and to the committee, he says:
"Taking the specific example about a person who has been removed from a practice's list, in the first place a contractor would have to demonstrate that it had good reason to remove a patient from its list. If this was judged to be badly founded, the contract terms would provide for sanctions to be imposed by the Health Board."
In other words, there would be redress for the wronged patient.
"Patients would instigate this process by using the formal complaints procedure set down in the contract regulations as a feature to be included in all GMS contracts."
That takes us beyond Scottish statutory instruments into regulations that pertain to a contract. Again, the committee might want to consider that. How does somebody access the information if they find that a doctor has taken them off the list? The doctor might have a bad reason for doing that—for example, the patient might be about to complain about the doctor.
I also raised the third issue, which relates to the draft regulations under the heading "Compliance with legislation and guidance", and is the question of how strong the regulations and guidance are in terms of law. I asked the minister what the words "have regard to" mean, in the phrase
"have regard to all relevant guidance".
In terms of the force of law, where do the words come on a scale of 0 to 10, if 10 means "shall"? In his answer, the minister says that
"this wording is simply included to make it a term of a contract that … the contractor must have regard to guidance"
and that "have regard to"
"has its ordinary meaning".
I am not satisfied with that. I do not see why the wording could not be "shall comply in so far as is reasonable" or "shall comply in so far as is practicable with the guidance". That would be much stronger.
On David Davidson's amendment, I will wait to see the minister's position and I will reserve mine.
Like everyone else here, I generally welcome the bill. The modernisation of primary medical services is clearly required. I also welcome the minister's announcement of extra funding, particularly for rural areas, and I hope that we will hear more detail about where that money will go. I have concerns about the remote and rural areas research initiative, which has been an important driver of innovation and quality in medicine in rural areas. It is due to come to an end and it is not clear what will follow it. I also hope that the minister will make an announcement about where the Executive is with the transitional arrangements for inducement practices, because it is not clear where it has got to and there is concern about that.
I support Shona Robison's amendment; I share her concerns about provision in rural areas and the recruitment of GPs. I hope that the health boards that cover rural areas will be empowered to employ salaried general practitioners, but even that is not the answer because there would be recruitment problems. It should be noted that one of the things that affects the recruitment—and particularly the retention—of GPs, as well as their morale, is the paperwork that is involved in their daily lives. I hope that the regulations that follow the bill will not add to that paperwork, but that they will streamline it. Otherwise, we will simply have an adverse effect on GPs' morale.
I am aware that the provisions in the bill have been generally welcomed by doctors, but I am not sure that the public have much awareness of the bill. Primary medical services are going to look a bit different in future and I am not sure that that is being communicated to the people out there.
People are quite happy that, when they call a doctor out of hours in an emergency, a different doctor from their own will respond. That is accepted as the norm nowadays. I am not sure that people are ready to accept that, in cases of routine care such as the monitoring of diabetes, their own doctor might choose not to do that and that they might have to go to another practitioner for monitoring. That change in primary medical services has not been put across to the public and I will be interested to hear from the minister how such information sharing will take place.
I will say a few words about the new GP contract and quote from Doctor magazine on 4 December this year:
"The new contract may create ‘tunnel vision' among GPs, warn authors of a report on NHS quality … They say rewards for meeting quality targets will have benefits for the health service, but at the expense of areas not covered in the new GMS deal."
I have looked at the quality indicators and one cannot argue with many of them. There is a page and a half of indicators for coronary heart disease, which adds up to 121 points. There is a page for stroke and a page and a bit for diabetes mellitus, but I have not added up those points. Then we come to the quality indicators for mental health, which is probably a huge part of a GP's work load, and the number of points is tiny at 41 points, a huge number of which are for monitoring patients with severe mental health problems. In fact, three of the points are for monitoring people on lithium. I am concerned that, yet again, mental health is to be the cinderella. It has been the cinderella of the health service for a long time and it looks as though it will be the cinderella of primary medical services.
Although I want that point to be addressed, as well as the rural issues, I welcome the bill in general, and I will support Shona Robison's amendment.
I thank everybody who helped us on the Health Committee, especially the clerks and SPICe, because everything was new to me.
I will vote for and support the bill because I have no difficulty with its principles. I spoke to a GP last week who was desperate that the bill should go through. He was terrified that something would hinder its progress and therefore the implementation of the new contract. I assumed that he was one of those who had voted for the contract. He said, "Absolutely not." He said that he knew few folk who had voted for the new contract, but that they were all desperate to get on with it. The reason was that uncertainty breeds doubt, and more uncertainty, and that makes for low morale, which we are trying to improve. Morale in general practice is at the lowest that it could be; let us hope that the bill does the job.
As a member of the Health Committee, I spoke to people throughout the west coast of Scotland, which was very interesting. Patients in the north-west of Scotland are asking their general practitioners what will happen to them if their doctors opt out of the new contract. Patients are worried about what is going on; perhaps they need more education about what the changes will mean for them.
It is my understanding that general practitioners in rural and remote areas will have a conscience and provide cover as before, so they have fewer choices than they would have if they worked in towns. GPs in such areas cover vast distances and one house visit could take hours—it might involve both a car and a boat journey. In town, the general public do not understand the changes in primary care; they are more focused on the loss of hospitals and changes in their hospital services. They do not understand the impact that that will have on primary care services.
I spoke to a patient representative the other day who was on a local health care co-operative, which will be replaced by a community health partnership. She felt that she was in the dark, that everything was in limbo and that nobody was giving her any information about what was going to happen. We could improve on that. Although I fully support the bill, I do not have a blanket faith that everything will work out all right. I know that the Executive has the will and the money to put into the services, but one cannot put people where they do not exist.
Does Jean Turner have sympathy for the GPs in Lochaline and Lochcarron who worry that, if they opt out of the new out-of-hours arrangements, the community will turn against them? GPs have a moral commitment to their patients and if a patient dies, they will be cast out by the community.
I share that fear; I spoke to people in Gairloch who were accosting GPs in the street to ask those questions.
In order to plan ahead, doctors need to know who is opting in, who is opting out and who will stay the way they are. When a doctor opts out, as the minister said, they opt out of 24-hour cover and the health board has to cover for them. I wonder how that will work in rural areas, as well as in the cities. However, we have to go ahead and the proof will be in what happens when we get all the regulations and when the changes are working—because they have to work.
The regulations will put everything in place and only then will we see whether we have a comprehensive health service in Scotland. I support the bill.
I declare an interest as the wife of a retired general practitioner who still does locum work to try to keep the service going.
As I said in the stage 1 debate, the passage of the bill is crucial to the future of primary care throughout the United Kingdom because recent years have shown a severe crisis in morale in the service. Many GPs have been retiring early and in the past 10 years in Aberdeen there has scarcely been a GP over 60 years of age in full-time work.
Recruitment has been difficult, with too few medical graduates opting for a career in general practice and there has been an increase in the number of GPs working part time. Without the frequent use of locum practitioners, parts of Scotland would have been completely without primary care cover. I hope that the new contract will achieve the necessary balance between recruiting new GPs and retaining more of the older ones to make general practice a more attractive career option for medical graduates.
If Carolyn Leckie and Tommy Sheridan had their way, however, GPs would flee the health service like snow off a dyke—unless they plan to lock them into their surgeries and take away the keys.
The passage of the bill today will allow the implementation of the new contract to go ahead next April in Scotland as well as in England, which is important if we are to retain GPs in this country.
By and large, the terms of the contract have been welcomed by the profession. The focus on the primary care team and funding based on patient need as well as numbers will allow GPs to plan their work load more easily and, at the same time, to improve the service that they give to patients. For the first time ever, they will be rewarded for any enhanced services that they provide over and above the essential and additional services that most GPs currently give their patients. The transfer of responsibility for the provision of out-of-hours care to health boards will take an enormous load off GPs. Having been married to one for over 30 years, I know what that work load is.
Many GPs will opt out of out-of-hours provision, but many will continue to work out of hours in co-operatives, as they do now. In most parts of Scotland, that will be adequate and satisfactory provision. There is natural concern about out-of-hours cover in remote and rural areas, where alternative cover will be difficult to find when GPs opt out. I look forward to reading the report that the minister promised this morning.
There is still concern among GPs who run community hospitals that a nurse-led service at night in those hospitals could result in a lesser service to their patients. Patients will no doubt take time to understand how the contract will affect them, particularly when they hear that they might have to attend another practice for certain investigations or treatments. I hope that there will be an intensive education programme for them before the contract comes into force in April.
All in all, however, the new contract will be welcomed by the profession. I hope that, in the interests of doctors and patients, the passage of the bill today will result in the much hoped for and needed boost to morale, recruitment and retention in primary care.