Primary Medical Services (Scotland) Bill
Resumed debate.
We continue with the open debate on the motion to pass the Primary Medical Services (Scotland) Bill.
I congratulate Carolyn Leckie on the way in which she presented her amendments. Parliament is here to debate issues and Carolyn Leckie stood up for her principles. I disagree totally with the amendments and I am delighted that Parliament voted against them, but at the end of the day she was right to present her views in the way in which she did.
I agree with almost everything that the minister said about the bill. The bill will benefit the people of Scotland and will do much to improve the morale of hard-pressed general practitioners throughout the land. The minister has demonstrated that a major objective is the improvement of services to patients. That is an important point.
A local issue that affects the constituency MSP for Girvan is the fact that the Davidson cottage hospital in Girvan, which provides a 24-hour emergency service for minor injuries, may lose that service because of the effects of the bill. Two GP practices offered to cover the out-of-hours service provision with six doctors, but one of those practices has pulled back. As a consequence, the hospital's overnight services will be lost. Will the minister consider what steps can be taken in that respect?
The minister referred to new community hospital facilities. Girvan is fortunate in that it will be provided with such a facility in the not-too-distant future, but if the minor accident unit disappears, the service will be a lesser one than the one that we have at present. There appears to be a facility in the bill for the local health board to fund GPs on a salaried basis where practices will not do so. If so, someone could cover the out-of-hours services that are needed to maintain the existing service. I have spoken to the primary care trust, which considers that there is no way forward on the issue. However, there appears to be an option in the bill that would allow the service to continue.
I am sure that Cathy Jamieson, who, along with Adam Ingram, attended a public meeting on the matter, would very much welcome the interest of the minister in the issue. If the minister could become involved, something positive may come out of the situation for the people of Girvan, and the services at the Davidson hospital that they have enjoyed may continue for many years.
I am grateful to comrade Phil for his initial comments. When I returned to my office at lunch time I was pleased to find that I am still on the British Medical Association's Christmas card list. Indeed, I am still on the General Medical Council's Christmas card list. However, I am also receiving Christmas cards from Jack McConnell, so I suppose that that does not mean very much.
Beware!
I will, Dennis.
It is with regret that I oppose the motion to pass the bill; I do so because the bill has not been amended to reflect the very real and grave concerns that I expressed during this morning's debate. Members will be glad to know that I will not repeat those concerns now—that is my Christmas present to members—but I will raise a couple of other matters that were not discussed this morning.
GP practices enjoy absolute freedom in relation to the terms and conditions of their staff. On the one hand, we are told that the new contract needs to be implemented throughout the United Kingdom because cross-border competition would destabilise the job market for GPs. On the other hand, it seems that it is okay to have exactly that situation in relation to terms and conditions for primary care staff, not just across borders but across health boards and even in individual general practices. I am extremely concerned about the impact of the new contracts on terms and conditions. I am also concerned that there will not be enough money in the pot to fulfil the agenda for change commitments—although those do not go far enough—or substantially to improve terms and conditions for staff.
I emphasise that Tom McCabe must answer those questions. If he does not accept our position—that there is a threat of increased privatisation—will he tell us whether he has calculated the number of hours of work that will be required to fill the gaps in the provision of out-of-hours services and, indeed, if GPs opt out, of enhanced services? Who will do that work? How much will it cost? Are there sufficient resources to cope? Can the minister give me a categorical assurance that profits from, for example, locum services will not increase as a result of the new contract that the bill introduces?
I want to refer to Janis Hughes's earlier comments, as she misunderstood my point when she drew an analogy with medicine; I was talking about money and profit, not medicine. However, I am glad that she brought up a medical analogy. If randomised controlled trials—or something equivalent—had been carried out before we saw the spectre of private finance initiatives, compulsory competitive tendering or the latest private-profit adventure that I believe the bill represents, perhaps we would not be in the mess that we are in at Edinburgh royal infirmary and Hairmyres hospital, and perhaps we would not be in a mess over public-private partnerships in schools. I wish that a medical analogy had been used in those cases.
On a lighter note, I will not take up all the time that I have—that is another wee Christmas present to members, as I know that they all want to get away early. [Interruption.] Of course, if members do not want to get away early I can speak for another five minutes. I thank members for their Christmas cards and I apologise for not sending cards this year—I have not been able to do so because I have been so busy. I do not want anyone to think that I am not prepared to engage in the festive season. I take this opportunity to wish everyone a happy Christmas, and for all those who have not received Christmas cards, I hope that the Official Report will be enough.
I thank all the people who have worked hard on the bill and contributed to get it to this stage. I thank the witnesses from various organisations who came to give us information, and I thank the staff and my colleagues on the Health Committee. I also thank and pay tribute to both ministers because they made themselves available to the committee, often at fairly short notice. However we may disagree on fundamentals, and that happens once in a while, we must recognise that it has been a real parliamentary effort to get the bill to this stage in such a short period of time.
I am also pleased to welcome the ministerial approach of putting the patient at the centre of health care—that is in line with our approach. We also welcome and credit the fact that the minister is seeking to make access to health care more flexible, not only in health board areas but across health board boundaries and indeed throughout the NHS.
We also agree with the notion that money must follow the patient. Indeed, we have made the same point since we entered this Parliament. I would welcome any move in the next health bill that we have to deal with that makes it clear that the minister is following that line.
The bill is about patient care and access to quality primary care. The Conservatives are concerned about the time scale for delivering the changes and about whether we will be able to scrutinise properly any changes to those changes that might happen after we pass the bill today. Although the whole Parliament is worried about the major problem of delivering the manpower to meet the bill's requirements, we welcome the minister's decision to allow other health care professionals to take on new accredited primary care roles. That will reduce the load on GP practices. The minister once agreed with my comment that the question is not who should do what, but who can do what. That is how we must take primary care forward in this country.
I am concerned that health boards are centralising access to existing services. Will the minister tell us whether he will issue guidance on the application of the patient guarantee or on any potential loss of existing access to services in a GP practice? After all, the next practice might be 100 miles away and might be difficult for patients to access. I remind the minister that we must ensure that health boards can provide support to take primary care services forward, including providing access to consultant-led services, wherever they happen to be.
This morning, I said that I felt that the minister had agreed to deliver to us the draft regulations up to the passing of the bill. I have asked for his assurance that between now and when the regulations are finally laid before the Parliament the Health Committee will be fully involved in the process and will have access to those drafts. If the minister is happy to give me that assurance, I will seek the chamber's permission to withdraw my amendment. After all, it is about a point of principle, not political point scoring.
Indeed, it is the Christmas season and there is a certain amount of jollity in the chamber. I say to Carolyn Leckie that I am extremely pleased to be in room 101. On 2 May, one of her colleagues said that she wanted to turn the Scottish Parliament into a "Big Brother" series. Of course, those of us who remember the original room 101 in the book "1984" will also remember that when O'Brien asks Winston Smith about his true feelings towards Big Brother, Smith confesses "I hate him". At that point, O'Brien passes judgment on Smith. It is not enough to obey Big Brother, one must also love him, which is why O'Brien then utters the dreaded words, "Room 101". If that is the company I will keep when I am consigned to room 101, I am very happy to resist the forces of totalitarianism and to join Winston Smith in drinking gin for ever after at the Chestnut Tree. In reality, this lunch time I was at Carol Finnie's excellent establishment, the Railway Inn in Juniper Green. Before I move off the subject of "1984", I should also mention that for the whole time that he was outside room 101, Winston Smith succeeded in believing that two plus two equalled five.
The issue of privatisation and earning money from the health service has been one of the SSP's enduring themes in this debate. In that respect, I find it quite interesting that at half-past 6 in the evening on 20 November a certain Colin Fox was speaking at The Gaelic Club in Sydney, Australia. I note that the event was not free; indeed, he was charging eight Australian dollars for the privilege. Obviously, profit is okay in the SSP on some occasions.
A bargain!
Pensioners could get in for five dollars. Is the minister one of those?
I am really quite worried about some of our friends in the SSP.
I think that "obsessed" is the word that he is looking for.
Well, at least I have some obsessions that are worth having. [Laughter.]
I am really rather worried for Lord James Douglas-Hamilton, because I gather that in the socialists' Christmas poll he was voted top totty. Their affections now appear to be drifting towards Phil Gallie, but I have to say that my money is on James every time.
At least Stewart Stevenson does not have to worry.
Let me briefly make a couple of serious points about this important bill, which we are happy to support as a move forward in primary health care in Scotland. We think that there will be more difficulties in bringing the out-of-hours proposals home in rural areas than has perhaps been realised by health boards, by GPs and their representatives or by ministers. We would be delighted to hear that the ministers have done sufficient research to be absolutely sure that the new system can be brought in according to their proposed timetable.
Many years ago, my father had enormous difficulties as a single-handed rural GP in providing 24-hour-a-day cover, in a much simpler world than that in which GPs now operate. We want to hear a little bit more about whether, in this modern, complex world, we really have a fighting chance of achieving that.
We must now move on with an agenda for change minimum for pay for other workers in primary health care, because the issue is not just about GPs. No longer is it the GP and the GP alone who delivers primary health care.
I shall close with one final word to the SSP members, to illustrate how they fail—
Obsession!
Yes, absolutely, and we are on the case. I want to illustrate how little the SSP members understand. Curiously enough, the effect of taking the out-of-hours cover away from GPs and putting it in the hands of the health board is likely, on balance, to be a reduction rather than an increase in the amount of primary health care that is provided by private contractors, because I am sure that salaried doctors will have to form part of that provision. I leave that thought with the minister.
We will support the bill and, of course, our amendment, which will improve the motion that the minister has lodged.
I have no hesitation in recommending from the Liberal Democrat benches that Parliament pass the bill this afternoon. We do not support the two amendments that have been lodged on the ground that they are unnecessary. The SNP's amendment is unnecessary because the whole point of the bill is to give responsibility for the delivery of NHS services to the health boards. Neither the SNP nor the Conservatives felt it appropriate to lodge amendments to the bill at either stage 2 or stage 3. I therefore do not believe that it was necessary to lodge amendments to the motion this afternoon.
While he is on the subject, could Mr Rumbles tell us how many amendments he lodged on behalf of the Liberal Democrats as their health spokesperson?
It may have escaped Shona Robison's notice, but this is a coalition Executive and it is a coalition motion.
Excuse me, so it is!
It is amazing how often the SNP falls into that trap, but there we are.
I do not believe that it was necessary for the SNP to lodge an amendment to the simple and straightforward Executive motion to pass the bill.
I would like to focus on the Conservative amendment, which would require that all draft regulations be scrutinised by the Health Committee before they are laid before Parliament. I do not believe that that is necessary. This morning, we heard a pledge from Malcolm Chisholm to bring the redrafted regulations to the committee. For David Davidson to insist—that appears to be the point of his amendment—that the minister bring any change to the regulations, however small, back to the committee does not seem a practical way forward.
It is important to reiterate the point that both Malcolm Chisholm and Tom McCabe have moved mountains to get the draft regulations, and especially the draft UK regulations, before the committee as requested. They have already shown their good faith and therefore the Conservatives' amendment is not necessary or appropriate. I hope that David Davidson will seek to withdraw it.
I am not surprised that the SSP opposes the bill—it has a right to do so. This morning, Carolyn Leckie asked a series of rhetorical questions. It is a pity that neither she nor any of her colleagues bothered to ask the many witnesses who gave evidence on the bill any real questions—or, indeed, any questions at all. It was said this morning that none of them questioned the ministers at the appropriate time. They should engage in the democratic process and not simply grandstand at the end of debates. It is a pity that all members do not support the bill, as it is a real step forward for the health service in Scotland.
I thank my colleagues for what they have said during the debate. They have been generally supportive of what we are trying to achieve through the bill and have acknowledged how we have gone about our business. That is genuinely appreciated.
The bill represents one of the biggest changes to GP contracts since the NHS started. As befits such a major change, it has been a long time in preparation. The negotiations to agree the draft new contract for general medical services took almost two years and the profession has twice been balloted on it. The contract received strong endorsement on both occasions.
The bill that we will pass today enshrines the outline for the new arrangements. It will be followed by regulations that will contain much of the detail. The regulations will be underpinned by guidance and directions.
I have already had discussions with the Health Committee about the draft regulations and am looking forward to taking the committee's mind again before the regulations are laid. We always intended to have maximum engagement with the committee on the regulations because we recognise the regulations' importance. I give an absolute assurance that we will continue to work in that vein. So far, the committee has recognised the need for some give and take in its desire to see drafts and in relation to the work that the Executive must do to produce the regulations in time for them to be laid. As long as the committee continues to recognise the need for such give and take, I am sure that we can agree a way forward.
A lot of work is being done throughout Scotland to prepare for the new contract, but colleagues in Parliament have expressed concerns that the voice of the patient has been missing from the work that has been done so far. However, as we move to implement the contract, that part of the consultation process will come into play
Implementation of some elements of the contract, such as out-of-hours services, will lead to service redesign. Boards are under an obligation to consult locally on major service changes; we are committed to ensuring that that happens. I emphasise the obligation on boards. Boards should not present faits accomplis to the public; they should hear the views of local people and, as far as possible, take those views into account in reaching decisions. If ministers think that boards are not taking their obligations seriously, I assure members that we will have no hesitation in making our views clear to those boards.
Patients must have the opportunity to make their voices heard in respect of how the contract is implemented in their areas. Therefore, meaningful involvement will not be in the technical detail, but in the practical implementation in order to allow patients to have a say on the shape of new services. That is more important than giving them a chance to comment on the technical detail of an enabling bill.
Before I leave that issue, I want to remark on Mr Sheridan's road-to-Damascus conversion this morning to the Executive's way of thinking on his back bencher's amendments. I had no idea that I could be so persuasive; if I can convince the leader of the SSP within an hour's debate that our way of thinking is the right way of thinking, I might seriously have to reconsider Carolyn Leckie's kind offer. Who knows what I can achieve in a week? The SSP claims to have its finger on the pulse of the people of Scotland; it is a shame that its leader does not have his finger on the button.
The contract is a good example of the benefits of devolution. We have created a single contract throughout the United Kingdom so that patients in Thurso will receive the same benefits as those in Truro. However, on some issues we felt that we could do better for Scotland. Devolution has allowed us to do so. The best example of that is the revised Scottish allocation formula, which uses Scottish data to inform the main element of how practices are funded. A different formula will be used elsewhere in the United Kingdom. The formulas follow the same basic principle of patient need, but we wanted to use the more detailed data that are available here in Scotland. We wanted the formula to cover Scotland's unique geography to ensure that remote and rural areas are protected. Devolution has allowed us to achieve that.
I want to say a little about how the contract will be funded. The bill is accompanied by record levels of additional resources. Last year, we put £433 million into primary medical services and by 2005-06, that figure will have risen to £575 million, which is an increase of 33 per cent. One important point is that the money is guaranteed to go to primary medical services, which means that health boards will not be able to spend it on other priorities. The £575 million is governed by the gross investment guarantee, which guarantees that the money will flow into primary medical services.
The financial memorandum that accompanies the bill sets out the new funding streams for the contract. For instance, the global sum, which is money for the essential and additional services that practices provide, makes up 49 per cent of the total. Health boards cannot change that sum. Quality payments make up 18 per cent of the total. The amount that practices will receive will be governed by the number of points that they score, which means that health boards will have no discretion. Eight per cent of the total will be for enhanced services and the Executive will instruct boards that they must spend to a minimum level on those services. The money for health-board administered funds makes up 21 per cent of the total and will be used for premises and information technology, for example. The funding for the minimum practice income guarantee makes up 4 per cent of the total; again, boards cannot alter that. We will use our powers of direction to ensure that the financial commitment works in practice.
I have noted carefully what the minister has said. He has emphasised that services to patients must be improved and that there is no alternative to that. Does he agree that closure of the 24-hour minor accident service in the Davidson cottage hospital in Girvan will represent a loss rather than a gain if the new community service facility—if and when it is provided—does not provide 24-hour minor accident cover?
I agree with Mr Gallie that the national health service is a massive enterprise, but we are dealing with critical changes to primary care services and we would be best served if we concentrate on the issue at hand.
The increases that I mentioned will benefit patients directly, as well as benefit GPs' practices. Some of the money will be used, for example, to improve premises in order to ensure that they are suitable for delivery of care in the 21st century, but the bulk of the money will go on quality, which will create a direct link between the standard of care that is provided and the amount of money that flows into practices. That system will incentivise all practices to come up to the very best standards.
One of the main issues of concern as the bill has gone through the parliamentary process has been provision of out-of-hours cover. That was true even at stage 3, when Shona Robison lodged an amendment on rural practices and single-handed practices. I will address her points in a moment, but members might find it helpful if I mention some of the on-going work in preparing for the changes in out-of-hours services.
At present, GPs are responsible for care of their patients all day, every day. Many GPs delegate that care to others through, for example, out-of-hours co-operatives, but although they can delegate work, they cannot delegate responsibility. If the co-op arrangement fails for some reason, the responsibility goes straight back to the GP. We know that 24-hour responsibility is one of the main factors that deter medical students from going into general practice and we know that asking one group of staff to provide cover at night after a full day's work is not in the best interests of doctors or of patients.
The provision of the 24-hour service will depend on the location of hospitals as well as on GP practices and co-operatives. I thank the minister and Malcolm Chisholm for the recent decision in favour of the new hospital at Larbert in my constituency about which I and my constituents are very pleased. Will the minister try to ensure that there is genuine 24-hour provision for people throughout the Forth Valley NHS Board area, including the rural communities?
It is our firm intention—I will talk more about this later—that there be a 24-hour service for primary care services in Scotland's national health service whenever people need it, irrespective of where they live.
The bill allows GPs to transfer their out-of-hours responsibilities to health boards and it will be the responsibility of health boards to provide that cover. It could be provided through contracting with other providers or by employing staff directly to carry out that function. We are aware that this is a significant change, so we are supporting health boards as they plan how they will deal with their new responsibilities.
Early work by NHS boards shows that the arrangements that are being put in place throughout Scotland will be a combination of professionals and services including NHS 24, general practitioners, primary care nurses, hospital services, community nursing teams, some local authority services and others to provide round-the-clock care.
Some parts of the NHS are already well advanced in creating the team approach that is so fundamental to the new services. In the NHS in greater Glasgow, a team of doctors and nurses work together to deliver care to patients throughout the city and in Ayrshire, a local GP co-operative already has well developed and integrated services with a range of NHS services, such as community nursing and the community mental health service.
Let us be clear: the bill is not about cutting services; rather, it is about providing services in a way that is different and in a way that suits the needs and demands of patients in the 21st century. Anyone who needs access to primary medical services outside normal hours will get it. That is guaranteed.
Boards have made a good start in working with a wide range of partners in order to become ready to deliver services in a new way. I am committed, as is my colleague Malcolm Chisholm, to ensuring that that continues during the coming months.
I turn to the detail of the SNP amendment. As the Minister for Health and Community Care has already said, Shona Robison is confusing single-handed practices with remote and rural practices—they are not the same. There are many single-handed practices in Glasgow, for example, and equally, there are some reasonably sized practices in rural areas—for example, the inducement practice in Aviemore has six GPs.
On who can choose to transfer responsibilities, it is again important that we make matters clear. The vast majority of GPs in all parts of Scotland will be able to transfer responsibilities to health boards. It is only the small number of GPs who are in the most extreme geographical locations who will not. In response to concerns that Mary Scanlon expressed this morning, I assure her that GPs do not have to make instant decisions about whether to retain their out-of-hours responsibilities. Although practices can transfer their responsibilities from any time after April if their health board agrees, they are under no obligation to do so—the decision is theirs. The new system will not come into full effect until 1 January 2005, which gives GPs a year to make up their minds. Even after that date, practices that retain responsibility can choose to opt out at any point in the future, provided that they give the board the set period of notice. It is not a decision that GPs anywhere in Scotland must rush.
The issue of out-of-hours cover in remote and rural areas is a key priority. That is why the national out-of-hours working group had as its remit the responsibility to develop models of service design and delivery for a range of populations, from the urban through to rural and remote. Those models are consistent with the overall NHS reform agenda and help to develop guidance to the service. As Malcolm Chisholm said, the working group has recently produced an interim report, a copy of which has been passed to the Health Committee.
No one would argue that we do not need to ensure that the small number of GPs who cannot opt out are supported: they will receive additional funding. In addition to retaining the payment that GPs who opt out must give up, GPs who cannot opt out will receive a share of the out-of-hours development fund. That fund is increasing in size from £6.3 million to £10 million by 2005-06. They will also receive another payment to cover any difference between the total of those amounts and the locally determined premium that is payable to salaried GMS practitioners for providing out-of-hours services.
Of course, support is about more than money. Health boards in remote and rural areas will need to think about how best to attract GPs to remote areas and how to support them thereafter. For example, support might relate to providing guaranteed locum cover to ensure that GPs and their families can take the holidays that everyone needs to rest and refresh themselves.
Shona Robison's amendment refers to the problems that health boards will have in recruiting GPs to remote areas once the new contract is in place. However, those problems already exist and the other benefits that are contained in the new contract will help to address them.
However, those in rural areas, including those who are currently inducement practitioners, will benefit in other ways, through additional investment and the new Scottish allocation formula, which gives an additional weighting to reflect the extra costs that are incurred in providing services in remote and rural areas. Equally important is that practitioners will also benefit from the end of the existing arrangement, whereby any new income secured over and above the agreed national yardstick has been, in effect, clawed back from inducement practitioners. In future, they will be free to agree with the boards contracts that give a fair reward for all the work that is done. That alone will make remote practices a more attractive option for GPs.
This morning, Eleanor Scott raised a point about inducement practitioners; I reassure her that their needs have not been forgotten. We are close to agreeing a deal with the Scottish General Practitioners Committee that will set out how those GPs will transfer into the new contract, particularly in relation to calculation of their new global sum. That should help to reassure that small but essential group of GPs.
GPs who cannot transfer their responsibilities comprise a small but important group of doctors and their needs have not been forgotten. Work in relation to them will continue in the coming months in order to safeguard their interests and, importantly, the interests of their patients. The SNP amendment is, therefore, unnecessary and should be rejected.
David Davidson's amendment says that the Health Committee should see all regulations relating to the Primary Medical Services (Scotland) Bill in draft form before they are laid before Parliament. I hope that my comments towards the start of my speech have given him the reassurances that he sought. I hope that I was clear enough to convince him to withdraw his amendment. If I was not, I urge members to vote against it.
One last point—
I bet it is a long one.
It is three pages long, actually.
Eleanor Scott mentioned the way in which mental health is treated under the new contract—it gets rather more priority than she suggested earlier. Not only will routine mental health work be done under essential services, but there will be an enhanced service that deals specifically with the specialised care of people who suffer from depression. That sets out the standards that we will expect practices to meet in this important area. An enhanced service will allow increased specialism, which will enable more to be done in the primary care setting. Again, I hope that that reassures Eleanor Scott that depression and mental health are given due priority in the contract.
It is time to conclude the debate. Today, we will pass one of the first bills of the new parliamentary session: it seems only fitting that it is a bill that will benefit every man, woman and child in Scotland.